Primeros

Assisting People with Disabilities
in Case of Disaster
European Network for Psychosocial Crisis Management
Science Forum
Volume 14
Science Forum
Volume 14
Assisting People with Disabilities
in Case of Disaster
European Network for Psychosocial Crisis Management
Recommendations for Preparedness, Response and Recovery
Co-financed by the European Commission

Grant Agreement Nº ECHO/SUB/2012/640917
Grant Agreement Nº ECHO/SUB/2015/718665/ PREP17
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and Disaster Assistance
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ISBN-13: 978-3-939347-85-9
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authors and does not reflect the opinion of the source is cited.
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This document is protected by copyright. Any charge. Please contact the publisher to receive
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of the applicable copyright law. Quotations are, Protection and Disaster Assistance.
Project Partners European Network for Psychosocial Crisis Management –
Assisting People with Disabilities in Case of Disaster (EUNAD)
German Federal Office of Civil Protection and

Disaster Assistance (BBK)
Bonn, Germany
University of Innsbruck
Innsbruck, Austria
Charles University
Prague, Czech Republic
Centre for Psychotraumatology

Alexianer Krefeld GmbH
Krefeld, Germany
Norwegian Centre for Violence and

Traumatic Stress Studies
Oslo, Norway
University of Southern Denmark

Odense, Denmark
Contents
Preface 11
Convention on the rights of persons with disabilities 17
1. Introduction to EUNAD & EUNAD IP 19
2. Target Group Intervention Program 27
2.1 Disaster phases and inclusive disaster risk reduction 30

2.1.1 Phases of action 30
2.1.2 Disaster risk reduction and inclusion 32
2.2 Target Group Intervention Program measures 34

2.2.1 Risk-independent measures in TGI 38
2.2.2 Conclusion 40
3. Analysis of literature and guidelines: summary 45
3.1 Analysis of national and European projects focusing on psychosocial

support for disabled citizens in critical incidents and disaster situations 48
3.1.1 What should we do? Demands 54
3.1.2 Results and Outlook 55
4. Survey of psychosocial emergency care and uniformed services on their

experiences with people with disabilities 57
5. Hearing impairments 65
5.1 Research results 69

5.1.1 Danish study 69
5.1.2 Special needs and challenges in the medical rehabilitation of deaf
or hard-of-hearing individuals 73
5.2 Recommendations for Deaf and Hard-of-Hearing People 75

5.2.1 General recommendations 76
5.2.2 Emergency preparedness 77
5.2.3 Emergency response 79
5.2.3.1 Psychological first aid 79
5.2.3.2 Psychosocial aftercare 80
6. Visual impairments 83

6.1.1 Results from a population study of visually impaired individuals 85
6.2 Recommendations for the blind and visually impaired people 92

6.2.1 General recommendations 93
6.2.3.1 Psychological first aid 94
6.2.3.2 Psychosocial aftercare 95
7. Intellectual disabilities, dementia and autistic spectrum disorder 97
7.1 Literature analysis on people with intellectual disabilities 100

7.1.1 Definitions and terms: General learning disability/intellectual
disability/mental retardation 101
7.1.2 Persons with learning/intellectual disabilities in emergencies and
disasters 106

7.2.1 Needs and reactions of persons with intellectual disabilities in
case of disaster and possible supportive interventions for caregivers 113
7.3 Recommendations for people with intellectual disabilities, dementia and

autistic spectrum disorder 116
7.3.1.1 Training and preparation 119
7.3.3 Emergency recovery 128
8. Physical impairments 131
8.1 Review of research 133

8.2.1 No one left behind – The accessibility of medical and psycho-
social services following disasters and other traumatic events:
Experiences of physically disabled individuals in Denmark 136
8.3 Recommendations for physically impaired people 153

8.3.1 Emergency Preparedness 154
8.3.2 Emergency Response 154
8.3.3 Recovery (Psychosocial) 155
8.3.3.1 Implications for rehabilitation 156
8.3.4 Guidelines for communication and interaction with people with
physical disabilities 156
8.3.5 Specific recommendations 157
9. Key recommendations for assisting persons with disabilities in case of

disaster 159
9.1 Policy recommendations 160
9.2 Key recommendations for disaster management 162
9.3 Key recommendations for emergency/disaster managers, planners and

responders 164
9.4 Key recommendations for people with disabilities 168
9.5 Key recommendations for caregivers/family members/

helpers of people with disabilities 170
10. Guideline development and implementation: importance of

international cooperation and local tailoring 173
11. Sources 177
11.1 Research 178
11.2 Guidelines & Handbooks 194
11.3 Tools 202
11.4 Practice Examples 208
11.5 Acknowledgement 210

Table of figures
Figure 1: Adapted from Twigg, (2004) 31
Figure 2: Standard flow chart of target group intervention 35
Figure 3: Target group intervention measures for affected persons 38

Preface
Dear readers,
Psychosocial issues and tasks are by now a key fixture in the field of modern civil
protection. Providing psychosocial assistance for people who have had to experi-
ence emergency situations, serious accidents, terrorist attacks or catastrophes is an
integral part of crisis management and civil protection in Germany and its neigh-
bouring European countries. Emergency response personnel are now specially
trained with regard the psychosocial challenges involved in their line of work, and
are provided with professional support to process the things that they experience
during their deployment if required.
The quality of national and European psychosocial crisis management is ensured

through basic research, the evaluation of deployments and training, as well as
interdisciplinary and international cooperation and networking. Thus, the German
Preface • 13
Federal Office of Civil Protection and Disaster Assistance (BBK), which is part of the
Federal Ministry of the Interior (BMI), has organised numerous research projects
focusing on the sociological issues of civil protection since 2000; either at German
universities or carried out by the BBK itself. The BBK has worked together with
partners from various specialist authorities, fire services, police forces, aid organ-
isations, the Federal Agency for Technical Relief, churches, associations, societies,
insurance companies and other organisations to evaluate scientific findings in the
field of psychosocial crisis management, and has used these findings to develop
quality standards that are in line with international guidelines and that have now
been passed as binding within Germany.
Project work and collaboration with European partners represents a further key
component of the BBK’s quality assurance work in the field of psychosocial crisis
management. Thanks to funding from the European Commission, Directorate
European Civil Protection and Humanitarian Aid Operations – DG ECHO, the BBK
has been able to run several projects in the field of social science.
The BBK’s two most recent European projects – the second of which was also
coordinated by the BBK and the results of which are now available and presented
in the subsequent chapters – focused on the availability of psychosocial care and
treatment for people with disabilities in the event of serious accidents, attacks or
catastrophes.
The “European Network for Psychosocial Crisis Management – Assisting Disabled

in Case of Disaster (EUNAD, 2013–2014)” project focused on people with sensory
impairment. The follow-up project, entitled “European Network for Psychosocial
Crisis Management – Assisting Disabled in Case of Disaster – Implementation
(EUNAD IP, 2016–2017)”, also dealt with the psychosocial crisis management avail-
able to people with physical and mental disabilities and looked at the development
of pedagogical self-help toolkits for people with disabilities.
Research, training and workshops represented the milestones of the EUNAD

projects. The research is based on a multi-method approach; training activities
were carried out with different target audiences, and national and international
workshops were held to provide a space for experts to share their knowledge. The
“voices” of the disabled and their associations were integrated into all of these
steps.
Both EUNAD projects picked up on the demand of the UN Convention on the

Rights of Persons with Disabilities (2009) to guarantee the protection, safety and
appropriate treatment of people with disabilities in situations of risk, including
armed conflicts, humanitarian emergencies and natural disasters (article 11).
14 • Assisting People with Disabilities in Case of Disaster • Volume 14
The present recommendations on inclusive psychosocial crisis management

are on the one hand based on scientific studies on the situation facing people
with sensory, physical and mental disabilities in emergency situations, their
specific risk and protective factors, the consequences of the stress factors, and
their needs. On the other hand, these recommendations have been developed
and evaluated as part of an intense professional discussion with experts from
the field of civil protection and, in particular, from the field of psychosocial crisis
management as well as representatives from organisations representing people
with disabilities.
The recommendations are based on the time course of traumatic stress response.
This means we distinguish between preparedness, response, and recovery. Specifi-
cally we focus on the acute assistance provided in the first hours and days after the
event, and medium- to long-term measures. The recommendations include “best
practices” and incorporate national and European guidelines where available.
All of the recommendations are intended to clarify the needs of people with disa-
bilities, to sensitise professionals and to stimulate the implementation of appropri-
ate practical support. These steps are all necessary to make the notion of inclusive
disaster management a reality.
The recommendations are aimed at professionals working in the field of psychoso-

cial crisis management, including in acute, medium- and long-term assistance, risk
and crisis communication; at emergency response personnel and at the authorities
and organisations with security remits, as well as at those with political responsi-
bility, and should be incorporated into the relevant training programmes.
But they also address people with disabilities and their carers, so that their poten-
tial for help and self-help can be better incorporated into disaster management.
These recommendations on inclusive psychosocial crisis management could

not have been drawn up without technical expertise, a willingness to cooperate,
mutual respect and openness, and a constructive sharing of knowledge and com-
mitment to the cause.
I would like to thank all those involved from the partner organisations – the Uni-
versity of Innsbruck (Austria); Charles University, Prague (Czech Republic); Centre
for Psychotraumatology Alexianer Krefeld GmbH (Germany); Norwegian Centre
for Violence and Traumatic Stress Studies, Oslo (Norway); University of Southern
Denmark, Odense (Denmark) – and all of the other organisations that collaborated
on this project for their outstanding cooperation.
Preface • 15
Together with my colleagues Claudia Schedlich, Frederike Albers and Volker Harks,
as well as all of my colleagues at the BBK and partner organisations who were
involved, I hope that you find these recommendations inspiring and that this
volume provides you with new ideas and suggestions regarding your work in the
field of crisis management.
Yours
Dr Jutta Helmerichs
Head of Psychosocial Crisis Management
Federal Office of Civil Protection and
Disaster Assistance
Bonn, December 2017

Convention on the rights of
persons with disabilities
The EUNAD initiative targets the implementation and preparation of EU human
rights-related assistance programs for people with disabilities who are survivors of
disasters. In this context the statements of the UN Disability Rights Convention are
crucial.
Preamble
The States Parties to the present Convention have agreed as follows:
Article 1
The purpose of the present Convention is to promote, protect and ensure the full
and equal enjoyment of all human rights and fundamental freedoms by all persons
with disabilities, and to promote respect for their inherent dignity.
Persons with disabilities include those who have long-term physical, mental,
intellectual or sensory impairments which in interaction with various barriers may
hinder their full and effective participation in society on an equal basis with others.
Article 11
Situations of risk and humanitarian emergencies
States Parties shall take, in accordance with their obligations under international
law, including international humanitarian law and international human rights law,
all necessary measures to ensure the protection and safety of persons with disa-
bilities in situations of risk, including situations of armed conflict, humanitarian
emergencies and the occurrence of natural disasters.
Reference
https://www.un.org/development/desa/disabilities/convention-on-the-rights-
of-persons-with-disabilities.html
Introduction to 1
EUNAD & EUNAD IP
Claudia Schedlich, Frederike Albers, Gisela Zurek

Over the past decade there has been a rise in numbers of large-scale disasters
worldwide including in Europe. Complex natural and technical disasters as well
as other man-made major incidents like terrorist attacks have increased both in
frequency and intensity. Psychosocial crisis management (PCM) constitutes an
essential component of overall crisis management for major incidents in the acute
response phase and especially in mid-term and long-term support to improve
individual and community recovery and resilience. PCM encompasses the imple-
mentation of adequate supply structures in preparation for large-scale incidents,
the development of a comprehensive overview of the psychosocial situation, and
the preparation and implementation of acute, mid-term and long-term psychoso-
cial support provision.
The EUNAD (2013–2014) and EUNAD IP (2016–2017) projects are funded by the
European Commission, Directorate Humanitarian Aid and Civil Protection-DG
ECHO (Grant Agreement Nº ECHO/SUB/2012/640917 and Grant Agreement
Nº ECHO/SUB/2015/718665/ PREP17). Following the statements of the UN
Disability Rights Convention, the EUNAD initiative aimed to continue preparation
and implementation of EU human rights-related assistance programs for disabled
survivors of disasters. Concepts of psychosocial crisis management for people with
disabilities were developed, evaluated and communicated. This was conducted on
the basis of existing guidelines and the results of former EU projects, e. g. EUTOPA
and EUTOPA IP (IMPACT Guidelines for Early Intervention and for uniformed ser-
vices, Target Group Intervention Program (TGIP) for large-scale damage situations,
more information at: www.eunad-info.eu). The beneficiaries and the cooperating
and supporting authorities in the EUNAD initiative ensured a high standard of
empirical evidence as well as a link to civil protection and operational authorities.
Introduction to EUNAD & EUNAD IP • 21
Partners in the EUNAD initiative are:
German Federal Office of Civil Protection and

Disaster Assistance (BBK) (Coordinator EUNAD IP)
Bonn, Germany
www.bbk.bund.de
University of Innsbruck
Innsbruck, Austria
www.uibk.ac.at/psychologie
Charles University
www.ff.cuni.cz
Centre for Psychotraumatology Alexianer Krefeld
GmbH (Coordinator EUNAD)
Krefeld, Germany
www.alexianer-krefeld.de
Norwegian Centre for Violence and Traumatic Stress
Studies
Oslo, Norway
University of Southern Denmark
Odense, Denmark
www.sdu.dk/psykotrauma
Cooperating Partners and advisory board members in the EUNAD initiative are:
Group de Support Psychologique,

Luxemburg, Luxemburg, Charles Brück
Impact-National knowledge and advice centre for

psychosocial care concerning critical incidents –
Partner in Arq Psychotrauma Expert Group, Diemen,
The Netherlands, Michel Dückers
Israel Trauma Coalition. Response and Preparedness,

Jerusalem, Israel, Talia Levanon
Sociedad Española de Psicotraumatología y

Estrés Traumatico (SEPET-D), Madrid, Spain,
Francisco Orengo
Julius-Maximilians-University, Faculty of Human
Sciences, Institute for Special Education, Chair
of Special Education IV – Education for People
with Developmental and Intellectual Disabilities,
Würzburg, Germany, Thomas Spaett, Florian
Rubenberger, Moritz Kastner
Cooperating Partners in the EUNAD initiative are:
Federal Association for special education, Würzburg, Germany
The Association of German Professional Psychologists; project group:

emergency psychology for people with intellectual disabilities, Berlin, Germany
University of Cologne, Unit of Education and Rehabilitation for people with

intellectual disabilities and severe impairment, Cologne, Germany
University of Cologne, Unit of Education and Didactics for people with hearing
impairment, Cologne, Germany
German association of the deaf, Berlin, Germany
German Association of the blind and partially sighted, Berlin, Germany

Red Cross Austria, Innsbruck, Austria
Ministry of the Interior of the Czech Republic, Prague, Czech Republic
Police Presidium of the Czech Republic, Prague, Czech Republic
DG Fire and Rescue Service of the Czech Republic, Prague, Czech Republic
Standing Commitee on Crisis, Disaster and Trauma psychology EFPA,

Brussels, Belgium
Section on Crisis, Disaster and Trauma Psychology, Prague, Czech Republic
The Czech Union of the Deaf, Prague, Czech Republic
Czech club of hard of hearing, ASNEP, Prague, Czech Republic
Centre for Childern with Hearing Impairment Tamtam,

o.p.s, Prague, Czech Republic
National Council of People with Disabilities of the Czech Republic,

Nautis, the National Institute for Autism, Prague, Czech Republic
Social services center Tloskov, Tloskov, Czech Republic
Emergency medical service of the South Bohemian Region,

section psychology, České Budějovice, Czech Republic
The youth organization of the Blind and partially sighted, Oslo, Norway
Norwegian Association of the Blind and partially sighted, Oslo, Norway
STATPED – National educational service, Holmestrand, Norway
The National federation for combined vision and hearing loss, Oslo, Norway
The Norwegian association of youth with disabilities, Oslo, Norway
The Norwegian center for hearing and mental health, Olso, Norway
The Danish Association of the Physically Disabled (DHF), Copenhagen, Denmark
Odense University Hospital, Odense, Denmark
The Special Hospital for Polio and Accident Victims, Odense, Denmark
European Union of the Deaf, Brussels, Belgium
European Blind Union, Paris, France
The main objective of the EUNAD initiative is to develop guidelines to integrate

people with sensory, physical and mental disabilities in crisis management pro-
grams. To achieve this objective, EUNAD projects are subdivided into the following
tasks: Evaluation, Research, Workshops, Recommendations, Training and Toolkits:
• Evaluation: Establishing networks with associations for people with disabilities;

literature analysis of research about people with disabilities in psychotrauma-
tology; analysis of European projects on inclusive disaster management.
• Research: Organisations and professionals working in disaster preparedness

and response have insufficient knowledge particularly about trauma exposure,
specific reactions and coping mechanisms, and the needs and demands of peo-
ple with disabilities in disaster settings. Qualitative and quantitative studies on
people with disabilities in general psychotraumatology and their psychosocial
situation close this knowledge gap.
• Workshops: Extending the European network for psychosocial crisis manage-

ment by including associations for people with disabilities in local workshops
in each participating country and international workshops. National and
international workshops ensure an intensive expert exchange, the evaluation of
EUNAD recommendations and the dissemination of EUNAD results.
• EUNAD Recommendations and EUNAD expert group: Recommendations on

psychosocial support of people with disabilities and PCM during and after dis-
asters; building a EUNAD expert group that may serve as a precursor to a CECIS
module development. Results from all tasks will be integrated into the EUNAD
recommendations that serve as a basic framework agreement for the EUNAD
expert group.
• Training: A substantial gap exists in psychosocial emergency care for people

with disabilities in terms of secondary and tertiary prevention. This reveals
the need for specific training and education for various occupational groups
on psychosocial crisis management for people with disabilities. An essential
part of the EUNAD initiative is to offer training activities for different voca-
tional groups and the development of a training manual. Potential trainees are
officials responsible for disability management, civil protection authorities,
uniformed services, social workers and mental health professionals. Outstand-
ing experts involved in the training activities will be one source of members for
the EUNAD expert group.
• Toolkits for schools and facilities for people with disabilities: At the end of the first
EUNAD project there was a strong call not only to focus on the improvement of
skills among helpers but also to emphasize the strengthening of self-help com-
petences among individuals with disabilities. EUNAD IP develops and evaluates
educational toolkits for children and young people with disabilities in order to
strengthen their self-help competences and to improve their preparedness in
disaster settings.
Target Group 2
Intervention Program
Robert Bering, Barbara Juen, Claudia Schedlich, Gisela Zurek

EUNAD and EUNAD-IP belong to the family of European-funded EUTOPA pro-
jects that have emerged against the background of the marked increase in natural
disasters and major losses caused by technical failure or terrorism (e. g. natural dis-
asters: www.emdat.com) over recent decades. Major losses mean that many people
need care: those who were directly or indirectly affected, as well as their families,
victims, bereaved persons, witnesses, the affected community and relief units.
Aside from the medical treatment of those injured, the necessity of acute, mid-
term and long-term care has been increasingly recognized and advanced in recent
years. The need to incorporate psychosocial emergency care of those affected
from the start is uncontested among experts. This topic is also finding increasing
recognition in all European countries.
To mention a few examples, the 9/11 terrorist attacks in New York, the terrorist
attacks in Madrid 2003, London 2004, in Turkey, Belgium, France and Germany
2016, or in Turkey, Great Britain and Spain 2017, flood disasters and the tsunami
2004/2005 in Indonesia and Japan (2011) have demanded immediate response as
well as mid- and long-term strategies. Each event develops its own dynamic and
Target Group Intervention Program • 29
requires a great deal of commitment, creativity, flexibility, and resilience from

helpers. “The heterogeneity of traumatic events and their aftermath defies any spe-
cific guidelines, and there is a need for flexibility of interventions and adaptations
to specific circumstances.” (Hobfoll et al., 2007, 284)
In the actual case of a disaster, mid- and long-term stress reactions must be
expected in victims, witnesses, relatives and the bereaved, and rescue workers.
In this case it is the collective challenge to all professional helpers to ameliorate
suffering, support victims and assist them in returning to their normal lives. If we
want to sensibly integrate psychosocial crisis intervention programs in emergency
preparedness, response and recovery, we are dependent on minimum standards
that take into account the course of stress disorders. The main question is: accord-
ing to current research, which crisis intervention measures have proved useful in
acute, mid- and long-term aftercare in curtailing the risk of post-disaster stress
disorders?
Uncertainty regarding effectiveness and goal orientation are evident in the con-
ception and conduct of crisis intervention measures in acute, mid- and long-term
aftercare (cf. Bering, 2011; Bering et al., 2006). “No evidence-based consensus has
been reached to date with regard to effective interventions for use in the acute and
the mid-term post mass trauma phases.” (Hobfoll et al., 2007, 284). To cover this
topic, we would like to introduce the disaster management cycle and describe the
basic strategies of the Target Group Intervention Program. Moreover, we link this
knowledge to the need for inclusive disaster management for groups with special
needs.
2.1 Disaster phases and inclusive disaster risk reduction
2.1.1 Phases of action
How to define a disaster? A disaster is characterized by three key features: (1) a sud-
den beginning, (2) the collective experience of being affected by the disaster, and (3)
a collectively great degree of threat and destruction. After a disaster
• a large number of people are affected directly and indirectly,
• a large number of people need medical treatment and psychosocial support,
• there are great physical, social and mental challenges,
• regional emergency medical services – including emergency psychosocial

capacities – do not suffice,
• various occupational groups are involved and need to be coordinated (e. g. fire
brigade, rescue services, police, military, emergency medical services, psycho-
social acute help, physicians, psychologists and psychotherapists, political
policy-makers),
• central leadership and organizational structures for acute, mid- and long-term
care are necessary,
• the required assistance is highly complex,
• capacities for mid- and long-term care are usually overstrained; resources may
have been destroyed,
• security in one’s own surroundings may no longer exist; entire areas or regions
are affected,
• trust in public officials is put to the test and easily upset.
However, we have two options in disaster management. First, we can be prepared;

second, we can respond. In the Hyogo framework, (2005–2015) building resilience
of nations and communities has been the priority (see https://www.unisdr.org/we/

coordinate/hfa) in disaster preparedness. In this context the term action indicates
that crisis management is not just about reaction/response and recovery, but that
state-of-the-art crisis management should also largely happen before a (possible)
event (see Othman & Beydoun 2013). Disasters do not happen in a social vacuum;
they are embedded in time and space (Barton, 2005). When they happen they
interfere with a living, dynamic psycho-social system. Therefore, a chronological
view on crises sooner or later turns into a reflexive perspective (see Alexander,
2005), along the lines of after a crisis is before a crisis. The form of this reflexive
perspective usually is one of a – or better the – “Disaster Management Cycle” (see
e. g. Challen et al., 2012).
Among many other institutions and organisations, the US Federal Emergency

Management Agency (FEMA) uses and promotes a four-stage cycle. This cycle of
disaster risk reaction includes (1) mitigation (2) preparedness (3) response, and (4)
recovery. Terminology and some details differ, depending on organisations, coun-
tries or other users/promoters, but the main thoughts are sufficiently summarised
in the scheme below.
Figure 1: Adapted from Twigg, (2004)

Source: stg.allindiary.org/documents/2014/03/disaster-cycle.pdf
1. “Mitigation is the effort to reduce loss of life and property by lessening the
impact of disasters. Mitigation is taking action now – before the next disaster –
to reduce human and financial consequences later (analysing risk, reducing
risk, insuring against risk).” (FEMA) Mitigation includes efforts to prevent or
decrease the effects of man-made or natural disasters by the assessment of
threats to a community. These assessments include the likelihood of an attack
or disaster taking place. We suggest adding the long-term effects of disasters
on communities or parts of communities regarding their enhanced or reduced
resilience.
2. Preparedness includes planning, resource allocation, and training of individ-

uals. This phase also includes disaster response exercises which help people
practise what to do if a disaster occurs.
3. Response includes public donations, incident management, coordination,

search and rescue operations, damage assessments, handling of fatalities, etc.
4. Recovery involves cleaning, reinstitution of public services, rebuilding of pub-

lic infrastructure, and all that is necessary to help restore civic life, including
disaster assistance and crisis counselling.
2.1.2 Disaster risk reduction and inclusion
In the recent Sendai framework (2015–2030) the focus is laid upon disaster risk
reduction. Priorities for action are: understanding disaster risk, strengthening dis-
aster risk governance, investing in disaster risk reduction for resilience, and invest-
ing in disaster preparedness and to build back better in the recovery and rehabilita-
tion phase (see http://www.unisdr.org/we/coordinate/sendai-framework).
Regarding mental health and disability, the Sendai framework expert group rec-
ommends the prioritizing of mental health and disability
(http://pubdocs.worldbank.org/en/619761454942779225/Mental-Health-Well-be-
ing-Disability-A-New-Global-Priority.pdf1):
1 United Nations: Mental Health, Well-being and Disability: A New Global Priority. Key United
Nations Resolutions and Documents. 2015
1. Ensuring that disaster risk reduction (DRR) policies and programs always
include mental wellbeing and disability as a priority. The international com-
munity needs to include mental wellbeing and disability as a priority theme in
all DRR frameworks. Humans are emotional beings; their mental health and
psychosocial wellbeing play key roles in resilience, recovery and reconstruc-
tion. Integration of mental health and psychosocial wellbeing and the rights
of persons with mental or intellectual disabilities makes DRR more effective,
resilient and robust.
2. Adding targets for and indicators of mental health and psychosocial wellbeing
in DRR. The Hyogo Framework for Action 2 should include mental health
and psychosocial wellbeing as transformative new targets and as indicators to
represent subjective well-being towards optimizing resilience of people and
society.
3. Including persons with mental or intellectual disabilities in DRR: Disabili-

ty-inclusive DRR should always ensure the inclusion of persons with mental or
intellectual disabilities. Persons with mental or intellectual disabilities need to
be included in disability frameworks and movements; they cannot be excluded
from the benefits created by the progress made in DRR.
4. Developing guidelines on mental well-being and disability in DRR: Practical

global guidelines on mental wellbeing and disability in DRR should be devel-
oped in the United Nations system.
5. Including mental well-being and disability in all efforts related to peace and
security, development and human rights: mental well-being and disability
need to be mainstreamed in existing work to advance peace and security,
development and human rights, including the upcoming Post-2015 Develop-
ment Agenda, to optimize resilience in response to disasters.
6. Establishing a multi-stakeholder working group on mental wellbeing and

disability in the United Nations system: A multi-stakeholder focus group on
mental wellbeing and disability should be established as part of the stakeholder
group for DRR and sustainable development in the United Nations system.
In the context of assisting people with disabilities in case of disaster we must dif-
ferentiate between disabilities caused by stress response syndromes and disabilities
caused by hearing, visual, motor or mental impairment prior to the disaster. In the
first case we deal with secondary prevention of physic disorders; in the second we
address the issue of inclusive disaster management and the special needs of people
with disabilities.
2.2 Target Group Intervention Program measures
The Target Group Intervention Program (TGIP) was designed for secondary pre-
vention of chronic stress response syndromes in the response and recovery phases.
The idea of TGIP is to identify those who are at risk of developing psychic disorders
and to conduct a range of measures including psychological first aid, psychosocial
acute and mid-term support and if necessary, therapy and rehabilitation. This
might be necessary if survivors are at risk of developing stress response syndromes
with long-lasting mental disabilities.
TGIP focuses on individual mid- and long-term aftercare measures and aims to
connect to early intervention concepts as seamlessly as possible. We investigate
which measures are efficient at which point of the potentially traumatic process
during and after a disaster. It is beyond dispute that people in an existentially
threatening and impairing situation need support. One goal of efficient psycho-
social aftercare measures must therefore be the minimization of stress response
syndromes due to traumatic stress. How can we conduct successful secondary
prevention? In the past, the main aim and research focused on prevention of
posttraumatic stress disorder (PTSD). Today’s state of knowledge, however, is that
the impact of stress after a potentially traumatic experience is clearly more com-
plex, so that an empirical focus on PTSD does not do justice to the scope of stress
reactions. Acute stress reaction (ICD: F 43.0), adjustment disorder (ICD: F 43.2), and
posttraumatic stress disorder (PTSD – ICD-10: F 43.1) are some of the psychological
impairments, along with comorbid disorders in cases of long-term progress (e. g.
depression, anxiety disorders or somatization disorders as well as addictions). How-
ever, our approach in EUTOPA and EUTOPA-IP addressed the question of how the
functioning of those affected is impaired; we consider how to include the needs of
survivors with visual, hearing, motor and intellectual disabilities.
We distinguish between acute response and mid- and long-term intervention. To

achieve a risk group-related response, we have developed the TGIP, a secondary
preventive concept of individual psychosocial aftercare. Its purpose is to prevent
the development of mid- and long-term stress disorders following critical inci-
dents. Planning an intervention strategy in the scope of TGI in cases of major losses
is geared to the procedures of TGI with victims of violence (Fischer et al., 1999)
and soldiers of the German armed forces (Bering et al., 2003) and is adjusted to the
logistic and structural conditions of major losses. The fundamental differences

between the concept of TGI and other early intervention concepts are:
1. a screening instrument developed for the sole purpose of early detection of

persons at risk (Cologne Risk Index – CRI)
2. the distinction between risk-independent and risk-dependent intervention

measures
Early detection of risk factors that promote the development of stress disorders
plays a key role in this concept. To assess the risk, an appropriate questionnaire, i. e.
a checklist, is used that enables prognostic inferences about the coping progress.
After assessing each risk profile, individually customized interventions can be
suggested and initiated.
Figure 2: Standard flow chart of target group intervention
Figure 2 shows that TGIP distinguishes between measures that are offered regard-
less of the individual risk profile of the persons concerned and measures that are
customized to the individual risk profile (Schedlich et al., 2003). We assume that the
early detection of at-risk persons using the CRI and the customisation of interven-
tion measures enable economical planning that can guarantee the ideal support of
even large numbers of affected persons when staffing levels are low. It is empha-
sised that the reaction to extremely stressful experiences should not be viewed as
pathological or as the pre-stage to pathology. Many people temporarily suffer from
normal stress reactions and mainly need support in re-establishing resources and
returning to normality, not traditional diagnostic procedures or clinical treatment
(Hobfoll et al., 2007).
The basis of planning interventions for individual psychosocial aftercare is
1. orientation on the time criterion, to the process model of traumatic stress
2. orientation on the risk profile of affected persons, risk evaluation using the CRI
(cf. Bering et al., 2008)
The phase boundary is difficult to pinpoint in many disaster situations and in the
event of large numbers of injured persons because of the continuous violence,
sustained shock and lack of aid. Furthermore, it is often difficult to create a clear
boundary between an acute situation and a post-situation period; as a result, acute
measures may overlap with intermediate-term aftercare.
The risk profile for developing a stress disorder can only be assessed within the
course of the process. This poses the question of which promising intervention
measure should be conducted at which point in time. The question also arises as
to which interventions are appropriate for the different groups. To find answers to
these questions, the axis of time in fig. 2 has been divided into the acute phase (A),
the transition phase (B) and the impact phase (C). In addition, the standard modules
of target group intervention (see fig. 2) have been divided into risk-dependent and
risk-independent modules of target group intervention (see fig. 3).
In case of major losses and disasters, there are three condition criteria that influ-
ence the planning of an intervention in each case and that are distinctive to TGI:
1. At what point during the traumatic process does the intervention come into
action?
2. Under what network conditions is TGI implemented?
3. How many people are affected by a critical incident?

The number of affected persons and the availability of professional helpers are
pivotal to the setting (individual or group setting) and the extent of help pos-
sibilities. The objective is to offer adequate help to as many affected persons as
possible to prevent long-term disorders, while making ideal use of staff capacities.
The psychosocial aftercare for relief workers must also be optimised to prevent
psychological after-effects and sustain work capability. It is necessary and sensible
to provide a target group-oriented intervention strategy so that affected persons
as well as relief units are neither over- nor under-accommodated with supportive
measures.
The type of intervention is dependent upon the course of the process. Acute care
is central to phase A. Phase B describes the length of time between shock and early
impact. Psychoinformation and screening with the Cologne Risk Index are key
measures in phase B. Phase C leads into the graduated planning of intervention for
the self-recovery, switch and risk groups.
The acute care of affected persons through primary safeguarding and psycho-
logical first aid are among the risk-independent measures (phase A). Only after
the shock phase has subsided can psychoeducative information geared towards
the CRI, among other things, be implemented. Discussion of the results and brief
counselling conclude the passage into the early impact phase (B).
Monitoring, continuative diagnostics, individual counselling, family counselling

and acute trauma therapy are among the risk-independent intervention modules.
These interventions are allocated to phase C on the time base. Thus, the helper
orients their choice of intervention by the time base and the victim’s risk profile.
This means that we must disassociate ourselves from the somatological paradigm
of emergency medicine, to enable accessible diagnostics (psychological triage) at
the place of the incident and in immediate hospital treatment respectively. While
the training of emergency physicians and paramedics aims to enable them to
recognize and administer life-saving interventions at the place of the incident, if
possible, therapists and first aiders must be able to survey the complete course of
process and prevent the chronification of a stress disorder during a psychosocial
crisis intervention program. The somatic paradigm of emergency medicine thus
cannot be translated one-to-one to crisis intervention programs. In the following
we will specify the intervention modules of the target group intervention program
in order to characterize it more precisely. Interventions during the acute traumatic
situation, the impact phase and in the traumatic process adhere to the guideline: as
much as necessary, as little as possible.
In planning an intervention, it is important to distinguish between basic preven-

tion measures for all persons affected and tiered measures that depend on the
individual risk profile. In content the emphases vary depending on the point in
time of the intervention, i. e. whether interventions are offered in the context of
the acute situation, the impact phase or the traumatic process. The planning of the
intervention in the TGI context is described in the following chronological order,
whereby we distinguish between risk-dependent and risk-independent measures.
Figure 3: Target group intervention measures for affected persons
Before tiered, risk-dependent interventions become effective, basic psychologically

relevant measures, aside from medical treatment, must be implemented within the
scope of secondary prevention. These measures include acute care of those affected
by providing primary safety and psychological first aid. Psychoeducation and
screening with the CRI, discussion of the results, brief counselling and instructions
for self-help should not be implemented before the initial shock phase has worn
off.
2.2.1 Risk-independent measures in TGI
Acute care
In the acute situation and immediately thereafter, the following measures are part
of the primary care of those affected, independently of their risk profile:
• Medical treatment
• Safeguarding and protection for those affected
• Ensuring that all primary needs (thirst, hunger, warmth, hygiene) are met
• Distancing from the place where the event happened
• Information about the event (cause, extent)
• Information on the whereabouts of family members
• enabling contact with other family members
• grief support
• information about continuative help
• offers to talk
Medical care is always a priority when dealing with major losses. Acute psycholog-
ical care, however, is a key part of care and affects the way victims deal positively
with what they have experienced. The priorities are building relative safety and
primary care as well as clear information. Another paramount concern during this
stage is the recreation of social connections (Hobfoll et al., 2007). Information is
an existential human need – to know whether loved ones are unharmed and well.
Transparency and to an extent knowing the reasons for courses of action (medical
measures, necessary separation of families during medical treatment, shelter pos-
sibilities, contacts) are helpful in order to counteract the loss of control. Questions
that those affected have about the situation are not ignored but answered to the
best knowledge and correctly, since the victims have a pronounced desire to know
as much as possible at this time. Information must be presented in a brief and clear
manner since the intake capacity is extremely limited in the shock situation.
Transparency and calming attention are internalised positively in this situation

(Bengel, 2007; Lasogga & Gasch, 2000). Further measures, such as psychoeducation
and in-depth instructions for self-help etc. are not indicated at this early stage and
do not promise lasting preventive effects.
Psychosocial support measures in the latency phase and after (phase B and C)
Following the acute situation, those affected often have requirements regarding
the safeguarding of their daily lives and material resources, as well as safeguarding
the social network, depending on the situational context. The main concerns here
are providing appropriate counselling and support opportunities (e. g. regarding
financial support, legal clarification, finding missing persons), help with deal-
ing with public authorities and giving those affected information about these
opportunities. Depending on the level of damage to the person’s life context, this
support may be necessary over a long period (months to years). Victims of terrorist
attacks, for example, frequently need long-term support with legal actions against
the terrorists. In extreme cases these legal actions can go on for decades, like after
the bombing in Bologna in 1981. Disputes over monetary compensation, e. g. after
technical disasters, are also often linked to long preliminary proceedings.
Funeral services and commemoration services also need to be organized and sup-
ported. Affected persons may eventually need support in creating a memorial.
Ensuring that the above-mentioned support is provided as seamlessly as possible is

one of the goals of psychosocial aftercare after disasters.
The psychological aftercare measures mentioned in the following text focus on

individual secondary preventive support in dealing with traumatic experiences
and the reduction of stress disorders, as well as the prevention of long-term stress
disorders.
After the initial shock reaction has subsided, initial psychoeducative, informative
measures can be implemented. If psychoinformation is not possible at that stage,
e. g. due to deployment issues or for medical or personnel reasons, it can be also
offered at any later point in the course of the traumatic process. More specific
descriptions of the content and implementation of psychoeducational measures
can be found in volume III (cp. Zurek et al., 2008).
After psychoinformation, screening with the CRI-D is implemented in order

to gain a differentiated assessment of the individual risk profile. Depending on
the result of the CRI assessment, those affected are assigned to the self-recovery,
switchers or risk groups. The assignment of affected persons to the risk groups
depends on the level of points in the risk index and is the basis for target-oriented,
continuative intervention. The results of the assessment are always and only dis-
closed in individual contact. A differentiated description of the CRI for use in case
of a disaster can be found in Bering et al. (2008).
2.2.2 Conclusion
What does TGIP mean for our topic of disability management in crisis inter-
vention programs? We conclude that risk factor management for people with
disabilities is challenging and data on specific risk factors are not available. How-
ever, we point out that time course models, a flexible approach and the relation
of disaster response and preparedness affect our research strategies and basic
recommendations (Bering et al., 2015, Gerwinn et al., 2016). Our booklet is a first
step towards an inclusive TGIP. However, we have no tools to verify different levels
of risk in our groups with special needs. Our book summarizes literature surveys
(Chapter 3), experiences in practice (Chapter 4) and research in the field of disability
management (Chapters 5–8). Finally, we have formulated key recommendations
(Chapter 9). According to the UN Convention on Rights for Persons with Disabili-
ties, strategies for inclusive disaster management must be defined.
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Analysis of literature and 3
guidelines: summary
Barbara Juen, Alexander Kreh, Michael Lindenthal
Hedvika Boukalová, Simona Hoskovcová, Štěpán Vymětal
Claudia Schedlich, Gisela Zurek

Research analysis shows that there are substantial differences around the world
in the vulnerability and resources of individuals with disabilities in the wake of
a disaster or an emergency. In industrialized societies the inclusion of people
with disabilities is gaining importance in disaster and emergency management
concepts. Nevertheless, the needs of individuals with disabilities in a disaster or
an emergency are largely not met at the moment (Ha, 2016). In less developed
countries efforts are also being made to address the needs and requirements of
people with disabilities. People with special needs often face greater barriers in
case of emergency or disaster than people without disabilities (Paudel et al., 2016).
People with pre-existing disabilities are more likely to develop co-morbidities after
a disaster (Reinhardt et al., 2011). Research also shows that individuals with special
needs recover more slowly and less well from disasters. Although their needs after
a disaster are similar to those of people without disabilities, their recovery may be
more complicated and they require additional support (Stough, Sharp, Decker &
Wilker, 2010). Disasters or emergencies may have negative long-term psychological
effects on people with impairments. Findings indicate that individuals with disa-
bilities resulting from a disaster have an increased risk of mental health problems
and PTSD (post-traumatic stress disorder) symptoms after a disaster (Zhou et al.,
Analysis of literature and guidelines: summary • 47
2015). To sum up, we can say that despite previous efforts, disaster and emergency
response is still not disability-inclusive. The literature on the needs of people with
disabilities is limited. Further research is necessary to provide better knowledge
and awareness of the requirements of people with disabilities in the event of a
disaster or emergency. This could result in their vulnerability being reduced and
their resources being strengthened.
References
Ha, K.-M. (2016): Inclusion of people with disabilities, their needs and participation,
into disaster management: a comparative perspective. http://www.tandfonline.com/
doi/abs/10.1080/17477891.2015.1090387
Paudel, Y. R., Dariang, M., Keeling, S. J. & Mehata, S. (2016): Addressing the needs of
people with disability in Nepal: The urgent need. http://www.sciencedirect.com/
science/article/pii/S1936657416000066
Reinhard, J. D., Li, J., Gosney, J., Rathore, F. A., Haig, A. J., Marx, M. & DeLisa, J. A.
(2011): Disability and health-related rehabilitation in international disaster relief.
http://www.globalhealthaction.net/index.php/gha/article/view/7191/9933
Stough, L. M., Sharp, A. N., Decker, C. & Wilker, N. (2010): Disaster Case Management
and Individuals With Disabilities. http://redd.tamu.edu/sites/redd.tamu.edu/files/
Disaster%20case%20management%20and%20individuals%20with%20disabilities.
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Zhou, X. Song, H., Hu, M., Li, X., Cai, Y., Huang, G., Li, J., Kang, L. & Li, J. (2015): Risk
factors of severity of post-traumatic stress disorder among survivors with physical
disabilities one year after the Wenchuan earthquake. http://www.sciencedirect.com/
science/article/pii/S0165178115003613
3.1 Analysis of national and European projects focusing on
psychosocial support for disabled citizens in critical incidents
and disaster situations
Over the last 15 years, the European Commission (EC) has funded various projects
aiming to develop and optimize quality standards and multidisciplinary guidelines
(MG) in psychosocial crisis management (PCM) as well as to foster networking of
the institutions and professionals involved. Beside general guidelines on PCM,
some projects focus on different aspects:
• the needs and demands of specific sections of the population, e. g. children,

migrants, older citizens
• PCM in cases of terrorist attacks
• focusing on professionals; the target groups are e. g. uniformed services and

hospital staff
• PTSD, early intervention, mid- and long term psychosocial aftercare
• the development of victims’ associations
• building up networks
Projects and Guidelines (European and international)
Psychosocial Crisis Management in general
• Psychosocial Support in Situations of Mass Emergency European Policy

Paper (2001); Ministry of Health, Belgium and European Experts
• EU Exchange of Experts in Civil Protection (since 2002) under the head of

the German Federal Agency for Technical Relief (THW)
• Working Together to Support Individuals in an Emergency or Disaster

(2002–2004); British Red Cross (www.gov.uk/government/publications/
working-together-to-support-individuals-in-an-emergency-or-disas-
ter-british-red-cross-report)
• Informed. Prepared. Together – IPT (2008–2009) under the coordination of

the European Red Cross, (www.redcross.org.uk/About-us/Media-centre/
Press-releases/2009/July/Informed-Prepared-Together-Red-Cross-and-EU-
promote-community-resilience-to-crisis)
• NATO & OTAN: Psychosocial care for people affected by disasters and major
incidents: A Model for Designing, Delivering and Managing Psychosocial
Services for People Involved in Major Incidents, Conflict, Disasters and
Terrorism: Draft Nonbinding Guidance (2008),
(http://www.coe.int/t/dg4/majorhazards/ressources/virtuallibrary/mate-
rials/Others/NATO_Guidance_Psychosocial_Care_for_People_Affected_by_
Disasters_and_Major_Incidents.pdf;
www.coe.int/t/dg4/majorhazards/ressources/virtuallibrary/materials/UK/
Principles_for_Disaster_and_Major_Incident_Psychosocial_Care_Final.pdf)
• ISAC Guidelines on Mental Health and Psychosocial Support in Emergency

Settings (2007)
• Psychological Support for survivors of disaster (2008)
• Building Resilience Amongst Communities in Europe (embrace) – pro-

ject under the coordination of the Université catholique de Louvan (UCL)
Belgium, and the University of Northumbria at Newcastle (UoN), United
Kingdom (2011–2015), (http://www.embrace-eu.org/)
• Operationalizing Psychosocial Support in Disasters (OPSIC), EU FP 7 Project

(2013–2016) under the coordination of the IFRC reference center for psy-
chosocial support (http://cordis.europa.eu/project/rcn/108235_en.html)
Psychosocial Crisis Management in cases of terrorist attacks
• Citizens and Resilience (2005–2007); Stichting Impact, the Netherlands,

(www.impact-kenniscentrum.nl)
• Sharing European Resources for Victims of Terrorism – EURESTE (2005-

2006 and since 2007); Red Cross, Belgium, (www.eureste.org)
• Developing Standards for Victims of Terrorism (2006–2008); Intervict Uni-

versity, Catholic University
• Victim Support; Forum for Restorative Justice, The Netherlands
• Prevention of longlasting Disorders for Victims of Terrorist Attacks – PLOT

(2005–2007); University of Cologne, Centre for Psychotraumatology, City of
Cologne, Germany, (www.plot-info.eu)
Development of victims associations
• V-Net I and V-Net II: Network for victims of terrorism initiated by the
Asociación de Ayuda a las Victimas del 11 M, Madrid/ Spain
• SURVIVORS – Joint Response to Loss and Survival in Terrorism (2007–

2009); City of Cologne, Germany; City of Bologne, Italy; Asociación 11M –
Affectados Terrorismo, Madrid/Spain; Westminster Council, Social Services,
London/UK
• European Network for Affected by Terrorism – ENAT

Professionals, e. g. uniformed services or hospital staff
• Reinforce Rescuers’ Resilience by Empowering a well-being Dimension –

RED (2007–2009); Italian Red Cross, Regional Commitee of Piemont, Red
Cross-France, Universities of Turin and Pavia, Regione Autonoma delle
Valle d‘Aosta, Fonda Formación Euskadi, Impact, (www.cri.piemonte.it/
progetti/red)
• Improve the Preparedness to give Psychological Help in Events of Cri-

sis – IPPHC (2007–2009); Ministry of Heath, Hospital Camillo Forlanini,
Italy, European Experts, (https://webgate.ec.europa.eu/chafea_pdb/health/
projects/2006212)
• Psychosocial support for civil protection forces coping with CBRN – CBRN
Incidents and PSS (2011–2013); German Federal Agency for Technical
Relief (THW), Federal Office of Civil protection and Disaster Assistance
(BBK), Centre for Psychotraumatology, Germany; Impact, The Netherlands;
Direcctión General de Protección Civil y Emergencias Ministerio del Inte-
rior Gobierno de España, Spain, (http://www.bbk.bund.de)
Building up a network
• European Network for Traumatic Stress – TENTS and TENTS-IP (since

2007); The Netherlands, Germany, Portugal, United Kingdom, Finland,
Sweden, Norway, Turkey, Spain, Croatia,
(https://www.estss.org/index.php?s=TENTS)
Specific aspects, e. g. PTSD, early intervention, mid- and long

term psychosocial aftercare, specific target groups
• Nice-Guidelines: Posttraumatic Stress disorder (PTSD). The management of

PTSD in adults and children in primary and secondary care (2005)
• The Tents Guidelines for psychosocial care following disasters and major
incidents (2008)
• Dutch Guidelines – Psychosocial Support for Uniformed Rescue Workers

(2010)
• European Guideline for Target group Oriented Psychosocial Aftercare in

Cases of Disaster – EUTOPA and EUTOPA-IP (2007–2011), (www.eutopa-
info.eu)
• Multidisciplinary Guideline for early psychosocial interventions after disas-

ters, terrorism and other shocking events (2007)
• Enhancing disaster management preparedness for the older population in

the EU (PrepAGE) (2014–2016) under the coordination of the Austrian Red
Cross, (www.prepage.eu)
From these international and European projects and guidelines we summarize the
following remarks:
• The different projects advance psychosocial activities in the European countries

involved. They enhance national, European and international networking.
• The interconnectedness of relevant professional groups, institutions and politi-

cal authorities can only occur on a national level.
• The guidelines developed can be used as a basis to implement PCM in the Euro-
pean member states.
• The individual projects don’t advance an overall European process and concep-
tual framework for PCM. There is still no integrative and consensual process.
• The EU-funded projects on psychosocial support and psychosocial crisis man-

agement (PCM) offer recommendations on early intervention. A framework for
mid- and long term interventions is not well integrated.
• A common terminology on measures and interventions of psychosocial crisis

management has yet to be generated. In addition, measures of mid- and long-
term psychosocial aftercare have to be integrated in the MG of the EC.
Following the overview and these remarks, we would like to outline our main
question:
To what extent are the demands and needs of people with disabilities considered?
The main question in analysing the guidelines and project results is whether they
focus on the specific needs of people with disabilities in preparedness, in the acute
phase or in the mid- and long-term aftercare in larger incidents.
The World Health Organization (WHO) estimates that between 7 and 10 percent of
the world’s population live with disabilities. People with disabilities are often liter-
ally and programmatically “invisible” in different assistance programs. In Europe
in 2015 an estimated 17.5% of the population are older than 65 and 4.7% older than
80 years old. The prevalence of physical, hearing, visual and cognitive impairment
increases exponentially with age.
Most of the surveys of guidelines cited in this report show a lack of specialized
concepts for practical care, health care and psychosocial support and counselling
services for people with disabilities in disaster situations. In the field surveys there
were only few specialized doctors, no specialist therapy and a lack of specialized
medicines and treatments. Moreover, there were generally no referrals to specialist
services.
Therefore, it is necessary to take into account the statements on vulnerability:
• Populations at risk include people who have substantial pre-existing healthcare

problems and needs, e. g. people who have impairments.
• Evidence shows that people in these groups are more vulnerable than the gen-
eral population to suffering the welfare, psychosocial and mental health effects
of disasters.
• Impaired individuals are particularly vulnerable during the preparedness and

response phases to disasters.
• Factors that mediate or moderate children’s recovery after critical incidents

include disabilities.
3.1.1 What should we do? Demands
A disaster plan should also consider and plan for the needs of special groups, such
as those with sensory, cognitive or physical impairments, those who are mentally
ill, and frail elderly people. This requires planning and rehearsal, and the use of
tools such as targeted mapping of local populations so that special groups may be
accommodated within universal major incident plans. The key in responding to
special populations lies predominantly in being aware of them and their particular
needs. It is important to provide information to the affected population on the
emergency, relief efforts and their legal rights.
The wide occurrence of special populations – including people with disabilities

and elderly people – emphasizes the importance of:
• planning and coordination to meet the needs of special populations,
• understanding the cultural, ethnic and socio-economic factors involved in

working with special populations,
• training professionals from diverse fields: community workers, uniformed

services and healthcare staff,
• promoting public health activities and prevention measures,
• taking active steps to promote coping within communities,
• being aware of cultural expression, rituals and ceremonies,
• designing services of adequate duration,
• planning adequate rehabilitation services,
• collecting, verifying and disseminating information with respect to the persons

involved in the event.
3.1.2 Results and Outlook
We conclude that there are specific questions that lead to further aspects regarding
the special requirements of people with disabilities in large-scale damage situa-
tions:
• Do people with disabilities have special needs in large-scale damage situations?
• Are there specific risk factors for the development of trauma-related disorders?
• Are there specific resilience factors in the community of people with

disabilities?
• Which groups have no access to media due to disability (e. g. people with visual
or hearing impairments)?
• What methods may need to be developed for dissemination of information to

reach out to such people?
Further research is required in this field. It would be a big step forward if inter-
national and European projects were aware of the specific needs and demands of
people with disabilities. This would optimize the implementation and preparation
of EU human rights-related assistance programs for disabled survivors of disasters
based on the UN Convention on the Rights of Persons with Disabilities.
Survey of psychosocial 4
emergency care and uniformed
services on their experiences
with people with disabilities

As part of the EUNAD project (2013–2014) the Federal Office of Civil Protection
and Disaster Assistance, section Psychosocial Crisis Management, conducted a
survey to answer the following questions:
• To what extent do suppliers of psychosocial acute help come into contact with
people with visual and hearing impairment and other impairments in their
missions?
• To what extent are the special needs of people with sensory impairment and
other disabilities part of these suppliers’ education?
• How well prepared do they feel to fulfil these tasks?
• What needs and demands do they see for future actions?
One main supplier of psychosocial acute help in Germany is the predominantly

voluntary emergency pastoral care. A questionnaire was developed and dispatched
to almost all emergency priests in Germany through their co-ordinators in the
federal states.
Survey of experiences with people with disabilities • 59
The sample
71 questionnaires were evaluated altogether. The overall return rate was 15%.
• 69% of the respondents were male, 31% female.
• 51% worked in a uniformed service organization, 49% did not.
• 92% worked in psychosocial acute help, 8% did not.
• 51% of the respondents acted in a double function, as a psychosocial acute

helper and as a member of a uniformed service organization.
• 74% of the respondents had worked for a period longer than 10 years.
• 32% worked in a major city, 29% in a medium sized city, 14% in a small town,
and 24% in rural areas (1% did not specify).
Experiences in missions with people with sensory impairment
About 70% of the respondents indicated that when on missions, they have never
had contact with people with visual and hearing impairments or people with
multiple disabilities.
• 32% of the respondents have had contact with people with blindness and visual
impairments when on missions, 67% have not (1% did not specify).
• 30% of the respondents have had contact with deaf and hard-of-hearing people
when on missions, 69% have not (1% did not specify).
• 22% of the respondents have had contact with people with multiple disabilities
when on missions, 76% have not (2% did not specify).
• 36% of the respondents reported domestic emergencies with people with dis-
abilities, 16% evacuation, 14% road accidents, 11% fire, 10% violence, and 13%
other.
These results suggest that mission situations with people with disabilities are rare
and not part of everyday routine. This might explain why the topic is underrepre-
sented in the relevant curricula.
Training
Almost all respondents (96%) have completed continuing education in psychoso-

cial acute help. However only one quarter of respondents covered the topic “People
with sensory impairment” during their education. 76% reported less detailed or no
information about deaf and hard-of-hearing people, 77% reported less detailed or
no information about people with visual impairments and blindness.
• 96% of the respondents have had comprehensive education in psychosocial

acute help, 4% have not.
• 25% reported that the topic “people with sensory disabilities” was a topic during
their education, 25% did not (2% did not specify).
• On the question of how well their education prepared them to deal with deaf
and hard-of-hearing people, 47% answered “less prepared”, 29% “not at all”, 18%
“well prepared”, 6% “very well prepared”.
• On the question of how well their education prepared them to deal with people
with visual impairments and blindness, 59% answered “less prepared”, 18% “not
at all”, 17% “well prepared”, 6% did not specify.
• On the question of how well their education prepared them to deal with people
with multiple disabilities, 59% answered “less prepared”, 23% “not at all”, 12%
“well prepared”, 6% “very well prepared”.
Exercises
Only 3%–12% of the respondents have experienced exercises that included people
with a hearing impairment, visual impairment or multiple disabilities.
• On the question if actors were involved in exercises representing deaf and hard-
of-hearing people, 96% answered “no”, 3% “yes” (1% did not specify).
• On the question if actors were involved in exercises representing people with

blindness and visual impairments, 87% answered “no”, 12% “yes” (1% did not
specify).
• On the question if actors were involved in exercises representing people with

multiple disabilities, 88% answered “no”, 10% “yes” (2% did not specify).
The findings show that in exercises, which represent a crucial educational element,
people with disabilities were significantly underrepresented.
Subjective experience of preparedness
About half of respondents indicated that they do not feel well prepared in dealing
with people with impairments. Only 3% to 4% indicated that they feel very well
prepared.
• On the question if they feel prepared for contact with deaf and hard-of-hear-
ing people, 46% reported feeling “less prepared”, 27% “not prepared”, 23% “well
prepared”, and 4% “very well prepared”.
• On the question if they feel prepared for contact with people with blindness
and visual impairments, 48% reported feeling “less prepared”, 18% “not pre-
pared”, 31% “well prepared”, and 3% “very well prepared”.
• On the question if they feel prepared for contact with people with multiple
disabilities, 52% reported feeling “less prepared”, 31% “not prepared”, 14% “well
prepared”, and 3% “very well prepared”.
Open questions
At the end of the questionnaire, respondents were asked to identify the particular
challenges entailed in dealing with deaf/hard-of-hearing people and those with
visual impairments/blindness when on missions, and to suggest what content in
particular should be included in their training or further training.
Respondents identified the following main challenges when dealing with blind or
visually impaired people:
• Helpers should basically be made aware of the particular situation of these

people and their specific needs.
• More comprehensive information dissemination is necessary. Information e. g.

on the situation and environmental conditions, planned measures, and nec-
essary decisions must be continuously communicated. This information must
be clearly and comprehensibly formulated and must take into account the fact
that the people concerned are not able to verify visual information.
• It is important to listen carefully and to find out precisely what the people with
disabilities need.
• The additional time required (for comprehensive communication of informa-

tion, transport etc.) and the requirement for more staff and more oversight
were mentioned as special requirements for these missions.
Respondents identified the following challenges above all when dealing with deaf/
hard-of-hearing (D/HH) people:
• Helpers should basically be made aware of the particular situation of these

people and their specific needs.
• The core challenge on missions dealing with D/HH people is the communica-
tion barrier. In order to enable the best possible communication with D/HH
people, it is considered necessary to implement alternatives to verbal commu-
nication methods in advance and to practise the use of these. Written informa-
tion material and pictograms should be developed in advance.
• Verbal and written communication in simple, clear sentences must be prac-

tised. This also applies to appropriately louder speaking for hard-of-hearing
people.
• Possible access to sign language interpreters should be known in advance.
• The additional time required (for comprehensive communication of informa-

tion, transport etc.) and the requirement for more staff and more oversight
were mentioned as special requirements for these missions.
Respondents assessed the inclusion of this topic area in training and further train-
ing as necessary. They criticised the fact that so far, little attention has been paid
to it in the field of missions and civil protection. The following content should be
particularly taken into account in training and further training:
• Basic knowledge about different forms of impairment, their causes, levels of

impairment and effects
• Promoting increased awareness and understanding for this target group and
overcoming inhibitions
• Basic competence in communication with deaf people, basic knowledge of sign

language
• Giving blind and visually impaired people as sense of orientation
• Legal principles
• Principles according to Hobfoll et al. (2007), communicating safety, calming,

self-efficacy, connectedness, and hope, adapted for people with disabilities.
In terms of didactic methodology, respondents proposed that:
• People with disabilities should be included as instructors at training activities
• Training activities should be developed in collaboration with associations for

people with disabilities
• Practical exercises should be a core element of training activities, e. g. giving

orientation and communication.
Conclusion
In the light of the results from the survey and from the interviews with teachers of
uniformed services and professionals in mid- and long term psychosocial support
(psychosocial acute helpers, social workers, psychotherapists), it becomes apparent
that the needs and demands of people with disabilities are severely underrepre-
sented in the relevant training programs.
Accordingly, an essential demand of all respondents and the EUNAD initiative is

to integrate this content into the existing curricula for e. g. uniformed services,
psychosocial acute helpers, social workers, psychotherapists, medical doctors, and
to include it in regular training courses and exercises.
Hearing impairments 5
Robert Bering, Philipp Benz, Florentine Gerwinn,

Lena Richter, Jennifer Söhn
Ask Elklit, Tina Jeppesen, Angelina Isabella Mellentin, Lotte Skøt

The EUNAD projects aim to improve the EU human rights-related assistance
programmes for the disabled survivors of disasters. This part refers to deaf and
hard-of-hearing (D/HH) individuals.
All people are vulnerable when disaster occurs, but D/HH individuals are particu-
larly vulnerable because of their inability/limited ability to hear sounds which
affects their ability to obtain and share information. When exposed to a traumatic
experience all individuals have a right to post-disaster medical and psychosocial
services; therefore D/HH individuals should also have a right to them. The Con-
vention on the Rights of Persons with Disabilities (CRPD, 2006) provides the full
range of rights for persons with disabilities, including during situations of armed
conflict, humanitarian emergencies and the occurrence of natural disasters. Many
European countries have signed and approved the CRPD. This means that State
Parties and public authorities have an undeniable responsibility to ensure that first
response, healthcare and trauma-informed aftercare services are adapted to meet
the specific needs of people with disabilities, including D/HH individuals. Despite
the responsibility for the CRPD, the specific needs of D/HH individuals are often
excluded from services across Europe. This is probably due to the lack of research
evidence available and services that are poorly informed about what should be
done for D/HH individuals in the event of disasters.
D/HH individuals constitute a significant minority group in countries of the

European Union where 20% of the population is estimated to have some form of
hearing loss. For example in Germany, the biggest country in the EU, there are an
estimated 80,000 deaf people and another 16 million people with some form of
hearing loss. An important fact is that around 140,000 of them need an interpreter
for sign language (Wirth, 2010; Hintermaier, 2007).
The preferred communication methods for D/HH individuals vary greatly

depending on the degree of hearing loss and cultural orientation. Communication
methods include different sign languages or Sign Supported Communication,
Mouth-Hand-System, hand alphabet (typically used to spell out names, places or
other words that do not have a particular sign), lip-reading and spoken and written
language in the mother tongue. A percentage of the D/HH individuals have chosen
to identify with the Deaf community which is a cultural and linguistic minority
Hearing impairments • 67
group centred on using sign language as their communication method. Sign

languages are fundamentally different from the spoken language in the country
where they are used, and are recognized as an independent language (Wirth, 2010;
Hintermaier, 2007).
In relation to the main subject of this international project, there are only a limited
number of international studies that have researched the issue regarding one or
more of the post-disaster services (e. g. Øhre, 2017; Øhre et al., 2015; Engelmann,
2013; Barnett, 2002). All these studies found that there was a lack of deaf awareness
among the professionals working for the different services. Deaf awareness means
having an understanding of: (a) the difficulties faced by D/HH individuals when
attempting to communicate with hearing individuals, and (b) how to minimize
these communication difficulties. Studies from the USA, Norway and England
that examined the general healthcare experiences of D/HH individuals and the
difficulties experienced by deaf individuals when accessing primary healthcare
and accident and emergency services found that the majority of D/HH individuals
faced communication difficulties when attempting to retrieve information from
health staff either directly and/or through relatives/sign language interpreters.
Another finding was the difficulty for D/HH individuals in finding a sign language
interpreter, especially in emergency situations. Furthermore, two of the studies
reported that poor communication can lead to dangerous misunderstandings
about treatment and compromise the health of D/HH individuals. Two studies
about the experience of D/HH individuals with accessing trauma-informed after-
care services from the USA reported a lack of services targeting D/HH individuals,
which resulted in difficulties in finding clinicians/therapists that could meet their
specific communication needs (Wirth, 2010; Hintermaier in M.,Tsirigotis, C., 2008).
It is often necessary for deaf individuals to have a sign language interpreter to

assist with communication, but they are rarely available. In small areas with fewer
interpreters, deaf individuals often end up having to use the same interpreter for
more than one situation. This is problematic because some deaf individuals report
feeling uncomfortable sharing intimate trauma experiences with an interpreter
they would have to use in other situations.
All-deaf support groups in mental health settings are rarely available because D/
HH individuals are a minority group. The studies mentioned show the important
communication difficulties that D/HH individuals face when accessing services,
and most of the studies provide suggestions and recommendations for how
services can be improved. The findings however, cannot be generalized to fit the
experiences of D/HH individuals all over Europe, and therefore there is an urgent
need for studies investigating the experiences of D/HH individuals when accessing
services after trauma or disaster.
References
Barnett, S. (2002): Communication with deaf and hard-of-hearing people: a guide for
medical education. Acad Med. 2002 Jul; 77(7), 694–700
Engelmann, A. (2013): Responding to the deaf in disasters: establishing the need for
systematic training for state-level emergency management agencies and community
organizations. BMC
Hintermair, M. (2007): Psychosoziales Wohlbefinden hörgeschädigter Menschen.

Internationale Arbeiten zur Gebärdensprache und Kommunikation Gehörloser,
Band 49. Seedorf: Signum Verlag
Hintermair, M. & Tsirigotis, C. (Eds) (2010): Die Stimme(n) von Betroffenen. Empow-
erment und Ressourcenorientierung aus der Sicht von Eltern hörgeschädigter Kinder
und von erwachsenen Menschen mit einer Hörschädigung. Heidelberg: Median-Ver-
lag
Hintermair, M. & Tsirigotis,C. (Eds) (2008): Wege zu Empowerment und Ressourcen-

orientierung in der Zusammenarbeit mit hörgeschädigten Menschen. Heidelberg:
Median Verlag
Øhre, B. (2017): Mental Disorders and Traumatic Experiences in Deaf and Hard of
Hearing Adult Psychiatric Outpatients. Oslo
Øhre, B., Uthus, M. P., von Tetzchner, S., & Falkum, E. (2015): Traumatization in deaf
and hard of hearing adult psychiatric outpatients. Journal of Deaf Studies and Deaf
Education, 20(3), 296–308
Mayring, P. (2015): Qualitative Inhaltsanalyse: Grundlagen und Techniken. Wein-

heim: Beltz
Wirth, W. (Eds) (2003): Trauma und Hörbehinderung. Internationale Arbeiten zur

Gebärdensprache und Kommunikation Gehörloser, Band 43. Seedorf: Signum
Verlag
Wirth, W. (2010): Schwerhörigkeit – Trauma und Coping. Qualitative Untersuchung

einer diagnostischen Fragestellung. Heidelberg: Median Verlag
5.1 Research results
5.1.1 Danish study
Ask Elklit, Tina Jeppesen, Angelina Isabella Mellentin, Lotte Skøt
The goal of this Danish study was to gain information about the experience of D/
HH individuals when accessing first response, healthcare and trauma-informed
aftercare services after experiences of disasters, and which improvements they
suggest to these services. As disasters are relatively uncommon in Denmark, the
range of D/HH individuals recruited was expanded to include individuals who had
experienced other crisis situations. The participants were nine D/HH individuals
that reported having experienced at least one disaster or crisis situation. Six of the
participants identified themselves as deaf (D) and three as hard-of-hearing (HH).
The participants filled out a list with traumatic events they or someone they knew
had experienced. On average the participants had been exposed to 3.3 potentially
traumatic events. Afterwards the individuals participated in a semi-structured
interview. Because of the low number of participants who had experienced a
disaster, they were asked hypothetical questions regarding recommendations for
professionals in the event of a disaster.
The difficulties the participants met during interactions with first response and
healthcare services could be divided into four major themes:
1. Lack of deaf awareness among first responders and/or healthcare professionals.
2. Problems gaining access to interpreter services at the hospital.
3. Healthcare professionals who relied on family members to translate informa-

tion to the D/HH patients.
4. Healthcare professionals who were unwilling to adjust their speech or try

different forms of communication.
Experiences
One major complaint of all participants was that the first response and/or health-
care professionals had a general lack of deaf awareness and lacked experience in
dealing with D/HH individuals; they were therefore unprepared to meet their
communication needs.
In Denmark, hospitals are required to provide and fund interpreter services for D/
HH individuals. Despite this, all the participants who use DSL as a communication
method experienced problems in gaining access to a sign language interpreter at
the hospital. One of the participants stated that he had been refused a sign lan-
guage interpreter on several different occasions at the emergency room due to
disputes about who should pay. These problems in gaining access to an interpreter
can create extra stress for D/HH individuals who are already in a crisis. Being a D/
HH relative to a patient in the hospital, and not a patient themselves, makes the
interpreter situation even more difficult, as in this type of situation the hospital is
not required to pay for a sign language interpreter.
When healthcare professionals turn to relatives to communicate with the D/HH

individuals, other problems can emerge. Among other things the patients’ feeling
of dependency can rise and there is a chance that relatives may inadvertently
leave out important details from the healthcare professionals. Furthermore, it is
an extra responsibility for the relative in an already emotional situation, and when
healthcare professionals rely on hearing relatives to communicate with the D/HH
patients, more problems arise when the hearing relatives are not available. Due
to busy work schedules, hospital personnel are often not willing to adjust their
speech or try other forms of communication. These things might result in the D/
HH patient not receiving the information they need.
In Denmark, there are no all-D/HH support groups for victims of trauma and their
relatives; the D/HH individuals must settle for trying to find a hearing support
group, which can lead to rejection as one of the participants experienced because
of the difficulties related to sign language interpretation.
The participants also expressed concerns regarding the limited number of crisis
psychologists who are trained to service the specific needs of the D/HH population.
Participants whose primary language was DSL reported preferring to work with a
crisis psychologist who is proficient in DSL. However, when seeking a psychologist,
the D/HH individuals who rely on DSL to communicate often ended up having
to choose a hearing crisis psychologist who understands trauma but does not use
DSL. Deaf individuals do not necessarily want to work with a deaf psychologist due
to issues of trust and confidentiality. One participant explained that in principle
everybody in the deaf community knows everybody else, so there is a chance that
one may meet one’s psychologist at a party, for example, and even though the
psychologist has a duty of confidentiality, it feels wrong.
For some D/HH individuals, the use of interpreter services is often necessary
during sessions with a crisis psychologist. The National Interpreter’s Authority has
a budget for psychological crisis treatment, and there is no limit to the number
of interpreting hours a D/HH person can get. The responsibility of booking a sign
language interpreter lies with the D/HH individual, not the psychologist. The use
of an interpreter can cause some challenges. One participant described working
with an interpreter as a strange experience because it disrupted the flow in the
conversation and his ability to communicate directly with the psychologist. Other
problems reported included a lack of chemistry with the interpreter and a fear of
being misinterpreted.
Another problem that can arise when D/HH individuals have to use a sign lan-
guage interpreter is that the likelihood of having to use the same interpreter for
more than one venue is high. One participant reported that he didn’t want to use
an interpreter from the centre he usually books from because he used the same
centre when he needed a sign language interpreter for work-related situations
and he always had in the back of his mind that the interpreter knew something
personal about him. Participants whose primary method of communication was
speech reported preferring to work with a hearing crisis psychologist who has
knowledge of deafness/hearing loss. One HH participant described not experienc-
ing any problems regarding communication because the psychologist made sure
that they sat directly opposite her when talking; another HH participant had the
opposite experience because the psychologist sat away from the light when talking,
resulting in the participant having to use all her energy on trying to hear what the
psychologist was saying.
Recommendations
The participants provided extensive suggestions for improvements in the provi-

sion of services for D/HH individuals who have experienced disasters/crises. They
would like to see more sign language interpreters made available, so that D/HH
individuals have a better chance of getting one at the scene of an emergency as
well as in crisis situations at hospital. Some participants also felt it was important
that funding be made available to finance sign language interpreters for D/HH
individuals who are relatives of hospital patients. With regard to trauma-informed
aftercare services, participants would like to see them expanded to include all-D/
HH support groups for trauma victims and their relatives as well as more crisis
psychologists who are trained to service the specific needs of the D/HH population
The participants reported that they felt that it was important that the different
professionals (first responders, healthcare professionals in hospital settings, crisis
psychologists) who are likely to encounter individuals with experiences of disasters
and crises acquire more knowledge about the varying communication needs of D/
HH individuals. Furthermore, they would like the knowledge of how to service the
needs of D/HH individuals to be incorporated into the training of first responders
and for brochures on deafness and hearing loss to be distributed to different work-
places (e. g. hospitals, doctor’s surgeries, psychology clinics).
Conclusions
The Danish study is the first of its kind to investigate the experiences of D/HH
individuals with accessing first response, healthcare and trauma-informed after-
care services in Denmark following experiences of disasters and crises. It was obvi-
ous to the participants that the professionals had had limited or no contact with D/
HH individuals in connection with their work, and therefore lacked the necessary
knowledge about how to communicate with them.
To sum up, the problems the participants met were: (a) problems gaining access
to a sign language interpreter at hospital, (b) healthcare professionals who were
unwilling to adjust their speech or try other forms of communication or who
relied on hearing relatives to pass on information, (c) a lack of all-D/HH support
groups, (d) problems finding a crisis psychologist with expertise in a specific area
who could also use sign language, (e) problems finding a sign language interpreter
for the sessions with the psychologist that the participants were not using in other
situations (e. g. work related) and with whom they felt comfortable.
Overall, the present study illustrates significant gaps in the provision of services
for D/HH individuals in the event of disasters and crises. The difficulties reported
by participants in accessing services are all centred on communication barriers.
When communication barriers are present it is highly likely that D/HH individuals
won’t receive all the information they require. There are certain things that can be
done to limit information deprivation and other problematic outcomes for D/HH
individuals. Our participants provided us with extensive suggestions for improve-
ments to service provision, including a list of practical recommendations for first
responders, healthcare professionals (hospital settings) and crisis psychologists.
Summarized, the recommendations for first responders are: Create and maintain
good eye contact, stay calm, use gestures (e. g. yes, no, come), point to body parts
and speak slowly, write things down, use cards with pictures/gestures or phones/
tablets with the sign language alphabet or that can translate speech into text and
vice versa. Learn basic sign language phrases (e. g. “Are you okay”), book an acute
sign language interpreter and if this is not possible, arrange a video conversation
with an interpreter. For healthcare professionals, the recommendations are: book a
sign language interpreter. Written notes are only appropriate for brief interactions,
not for more complicated discussions. Look directly at the patient, speak slowly
and clearly and make sure there is enough light. Be aware if the person’s hearing
aid has been removed or switched off and use for example phones/tablets with the
sign language alphabet or that can translate speech into text and vice versa, avoid
communication through relatives and ensure patients receive all relevant informa-
tion. For crisis psychologists, the summarized recommendations are: Sit directly
opposite the client and avoid looking at the sign language interpreter when speak-
ing and listening. Speak slowly and clearly and sit in a good light. Be aware of the
chemistry between client and interpreter and be aware of the importance of using
the same language interpreter for each session.
5.1.2 Special needs and challenges in the medical rehabilitation of deaf or hard-of-
hearing individuals
Jennifer Söhn, Philipp Benz, Lena Richter, Robert Bering
Research aim/Background
Within the framework of the EUNAD IP project, the Centre of Psychotraumatol-

ogy (CoP) of the Alexianer Krefeld GmbH did a mainly qualitative-based study that
aimed to identify challenges, requirements and coping skills in rehabilitation treat-
ments for hearing impaired individuals. An additional goal was to develop proce-
dural proposals for psychosocial aftercare following different disasters orientated
on the specific situation of deaf or hard-of-hearing (D/HH) individuals.
Methods
The study is based on 11 guide supported and structured interviews with D/HH
individuals at the time of their medical rehabilitation at the CoP. The interviews
analyses were oriented on Mayring’s qualitative content analysis. Additionally,
therapy and reflection sessions with an interpreter and systemic consultant were
included as were the results of the psychometric questionnaires (PDEQ, TAXON,
FLZ, SCL-90, PSSI, BDI, PTSS-10). The results were analysed with SPSS.
Results
All 11 deaf and hard-of-hearing participants in the research sample grew up with
hearing parents; nine of them had parents who could not speak sign language, and
two had parents with basic skills. All 11 participants reported disturbed commu-
nication and loss of information. The participants stated that verbal messages
had often not been understood within the family and reported feelings of social
exclusion and isolation. Seven participants reported experiences of physical
violence, eight reported experiences of psychological violence and five reported
experiences of sexual violence. Violence was experienced in the families of all
participants; this was mostly described as a result of the lack of communication
possibilities. In rehabilitation nine participants showed difficulties in reacting in a
sensitive manner, especially in taking on the perspective of other individuals and
reflecting their needs. These findings lead to the hypothesis that problems in every-
day communication with the above-mentioned consequences could be regarded
as a risk factor for posttraumatic stress disorders. In the context of treatment at the
CoP it became clear that diagnostic testing needs to be optimized because despite
interpreting, the psychometric questionnaires were only partly comprehensible for
the deaf/hard-of-hearing participants. For example, it was unclear if dissociations
occur among the participants because the descriptive concepts are not represented
linguistically in sign language. All participants had difficulties answering the
questions so that some parts of the questionnaires could not be evaluated. This was
especially the case for the “Peritraumatic Dissociative Experiences Questionnaire”
(PDEQ) and the “TAXON”. For the purpose of usable and meaningful diagnostics,
psychometric instruments should be culturally adapted for deaf and hard-of-hear-
ing people. In the context of the therapy sessions it became clear that stabilisation
techniques with visual, haptic and motor methods and exercises were preferred.
Attendance interpreters were also preferred in the meetings, while Verba Voice was
viewed critically in most cases. In the end, further professionalization of treatment
measures in these areas seems necessary to further optimize the rehabilitation of
D/HH people.
5.2 Recommendations for Deaf and Hard-of-Hearing People
The recommendations refer to emergency care and psychotherapy for deaf and
hard-of-hearing (D/HH) people. They contain instructions for action and state-
ments intended to serve the general interaction with affected persons in crisis
situations. In addition, recommended psychotherapy methods are identified that
proved to have a significant influence on treatment success. Recommendations are
subdivided under the headings “General recommendations”, “Emergency prepar-
edness”, “Emergency response” and “Psychosocial aftercare”.
The following recommendations are based on the results of two mainly qualitative
studies. The studies were carried out within the framework of the EUNAD project.
The University of Southern Denmark and the Center of Psychotraumatology of the
Alexianer Krefeld GmbH were the implementing institutions.
5.2.1 General recommendations
• Deaf and hard-of-hearing (D/HH) individuals react just like hearing individu-
als during times of crisis.
• Cooperation, networking, communication, exchange with associations of D/

HH people (“Nothing about us without us”) is essential.
• D/HH people mostly see themselves as part of a “linguistic and cultural

minority group”, not as disabled.
• D/HH people are a heterogeneous group according to their communication

skills. Some are unable to understand or read spoken language. Accordingly,
there might be a need to simplify spoken/written language. Some are able to
communicate in sign language or signed language (sound accompanying signs).
Communication skills depend on the time of becoming deaf or hard of hear-
ing (pre-, peri-, postlingual adaption), severity of hearing loss, other diseases/
disabilities, age, socialization and education. Universal design means taking all
possible kinds of communication skills into account.
• Use and adapt existing structures and services, try to find universal designs.
Services should be offered all over the country and should not be centralized.
• Sensitization of population (possible zero-responders) and professionals about

deafness/hearing impairment. Sensitization via:
– school education,
– information material (e. g. via flyer: as an example, the German government

distributed about 20,000 flyers including information about communication
with D/HH people; via the internet & media),
– training activities.
Sensitization should include:
– personal experience (e. g. in Israel, fire fighters are required to work for 30
hours with people with disabilities),
– cultural, ethnic and socio-economic factors,

– communication skills & possibilities to communicate (e. g. difficulties of

lip-reading, max. 30% of what is spoken can be apprehended),
– rights of D/HH people,
– learning basics about/in sign language.
• To ensure communication with deaf people who speak sign language, the pos-
sibility of calling interpreters in an emergency without going through a lot of
bureaucracy should be implemented. Financial issues for communication with
interpreters should be solved.
• Develop information material about acute, mid- and long-term services for
D/HH people after disasters. Produce different versions according to commu-
nication skills (written design, videos, media, internet, blogs etc.).
• Communication advice:
– Speak slowly and clearly, do not shout (as many hard-of-hearing people
show symptoms of hypo- and hyperacusia at the same time).
– Use basic signs, gestures or cards etc. that symbolize cohesion, help, security
etc.
– Ask what the D/HH person has understood or ask him/her to repeat your
communicated information to make sure he/she did understand your
message.
• Be careful: The way humour is used in deaf culture differs from the way it is
used in hearing culture. Humour can lead to misunderstandings.
5.2.2 Emergency preparedness
• Information (e. g. about existing dangers, the present situation and develop-
ment after disaster) should be communicated in a variety of ways:
– TV, media, Internet, SMS, Apps, etc. (in written text, spoken language, sign
language)
• Assemble a network of interpreters trained in specific fields such as medicine

or welfare (translating via video vs. in person) to be called upon during times of
emergency.
• Create information material for D/HH people in cooperation with deaf and
hard-of-hearing associations (in written text, spoken language, sign language)
including:
– rights of D/HH people,
– recommendation to have all necessary equipment (e. g. cell phone, hearing

aid with spare battery, etc.) with you,
– information about inclusive alert- and emergency-call-systems,
– stress reaction after disaster,
– general advice on how to cope with stress reactions,
– services and particularly how to access services (address & contact details).
• D/HH individuals should be educated in disaster preparedness, first aid, etc.

(e. g. via deaf and hard-of-hearing associations).
• Collect a voluntary database of people with disabilities for easier contact, crisis
communication and warning.
• Use multi-sensory attention alert systems (e. g. sound, vibration and flashlight)
and emergency call systems (e. g. telephone, SMS, FAX, apps, skype, internet,
e-mail).
• Develop possibilities of communication that work without electricity in case

electricity does not work during a disaster (e. g. writing with pencil on paper,
prepare pictures where D/HH people can show where it hurts, laminated sign
language alphabet etc.).
• Create inclusive standards for evacuation and emergency routines for employ-
ers/schools/communities/public-traffic systems/ public places etc. In particu-
lar, D/HH individuals should take part in disaster drills and simulations.
5.2.3 Emergency response
5.2.3.1 Psychological first aid
• Try not to separate D/HH individuals from each other or their relatives/
friends as these people promote their feeling of security and their chance to
communicate and receive information.
• When evacuating D/HH individuals let them take their compensatory equip-
ment with them if possible. (e. g. notebook, hearing aid, mobile phone).
• Specific communication advice:
– Ask for preferred means of communication (e. g. spoken language, written

language, sign language).
– Call sign language interpreters if D/HH individuals prefer sign language.

If you cannot arrange direct interpretation use remote sign language
interpretation.
– Maintain eye-contact and observe their facial expressions and reactions.
– Make sure there is enough light so they can see your face and what is going
on around them.
• Use signal symbols (e. g. logos, orange vest, and blanket) in chaotic situations so
that they can orientate visually.
• Do not wear helmets etc. outside the danger zone to give deaf and hard-of-
hearing individuals the chance to lip-read or see facial expressions.
• Be aware that deaf and hard-of-hearing individuals are most vulnerable in the
dark or while asleep when they cannot compensate their hearing loss with the
visual sense.
5.2.3.2 Psychosocial aftercare
• Psychiatric centres should be able to treat D/HH individuals in general not

only at one place per country. (Example for best practice: PsySurdus – an
online psychiatric service for the deaf including listening webcam, chat
and e-mail. Communication is based on French Sign Language (LSF) – Link:
http://www.sos-surdus.fr/.
• Make the preferred means of communication possible. Sign language interpret-

ers should automatically be provided and should be organized in advance – this
should not be the responsibility of the deaf and hard-of-hearing individual.
• Specific communication advice:
– Make use of possible technical devices/materials that can assist

communication.
– When using sign language interpreters, sit directly opposite the client and
avoid looking at the sign language interpreter while speaking and listening.
• D/HH individuals have the same needs as hearing individuals in the therapy
situation e. g. closeness, empathy, humour etc.
• Psychopathology: D/HH individuals suffer from same psychiatric disorders as

hearing individuals but there is evidence for generally increased incidence of
psychiatric problems in this population. Incidence of PTSD has not been fully
analysed so far. More research is needed. Hard-of-hearing people or people
who suffer an increasing loss of hearing often report of hyper- and hypoacusia
at the same time. This phenomenon is very similar to hyper-arousal syndrome
of traumatized people. Personnel should find out if a person is affected by this
syndrome.
• Therapy and Sign Language: Trauma treatment is difficult if it has to be done

via a sign language interpreter; eye contact is extremely important during
therapy, but this is lost if one uses an interpreter. The preferred option is for
therapists who speak sign language. If therapists are not able to speak sign
language it is preferable to use same interpreter if multiple sessions are needed.
Physically present interpreters are preferred rather than interpretation via
“Verba Voice”. Sign language interpreters should remain neutral and should be
unknown to the D/HH individual.
• D/HH individuals are used to being guided by hearing individuals; they also
expect that in the context of therapy. The content and procedure of therapy and
the role of the therapist as person who helps and supports the patient to help
himself must be explained.
• Visual material to support the therapeutic interventions can be useful.
• Stabilization techniques which make use of bilateral stimulation and body

movement are preferable over techniques that make use of imagination.
• Technical terms like “skill” or “trigger” must be paraphrased and explained. It

can be useful to agree with the patient on a gesture for these terms.
• Provide contact information for support groups for D/HH individuals

(e. g. crisis groups, bereavement groups).
• Information about important meetings/sessions should be provided in written

form.
Visual impairments 6
Trond Heir, Marianne Hansen, Audun Brunes

Visual impairment is defined as a decreased ability to see (Colenbrander, 2009).
About 40 million Europeans have a diagnosis of visual impairment, including
32 million with low vision and 8 million with blindness (Pascolini & Mariotti,
2012). The numbers are expected to increase due to an aging population, greater
frequency of systemic diseases, and more immigration from war-torn countries
(World Health Organization, 2014). Visual impairment can occur at any point in
life and has different causes, such as injuries, infections, systemic diseases, inherent
conditions, and congenital anomalies.
Vision is a key sensory modality for obtaining rapid and precise information about
the surrounding environment. Visual impairment may thus lead to increased
susceptibility for risks and hazards in daily life. Visual impairment may also be an
obstacle to gaining necessary and sufficient information in an emergency situa-
tion. For some individuals, this may challenge the ability to take care of their own
safety and security. A qualitative study that was part of the European Network for
Psychosocial Crisis Management (EUNAD) revealed that visually impaired people’s
daily lives included a range of hazards and potential threats (Saur et al., 2016). Fear
of daily accidents was more pronounced than fear of disasters. Some participants
reported avoidance of help-seeking in unsafe situations due to the shame associ-
ated with not being able to cope. Withdrawal and social isolation were important
issues.
However, little research has been done to examine the occurrence of post-trau-
matic reactions in individuals with visual impairments and whether they are more
at risk of mental health adversities than their sighted peers (Shaar et al., 2013). As
a sequel to the first EUNAD study, we wanted to gain more knowledge about type
and frequency of traumatic events among individuals with visual impairments,
and what impact various types of adverse life events may have on mental health.
We also wanted to know more about mental health in visually impaired people in
general, and what factors are important for good health.
6.1.1 Results from a population study of visually impaired individuals
Trond Heir, Marianne Hansen, Audun Brunes
Telephone interviews of people with visual impairment were conducted in Nor-

way between February and May 2017. Researchers from EUNAD-IP collaborated
with the Norwegian Association of the Blind and Partially Sighted in preparing
an interview guide and information for participants. The organization comprises
about 10,000 members. Participants were randomly selected among organization
members with low vision and blindness within four age groups: 18–35 years, 35–50
years, 51–65 years, and 66 years and older. Phone calls to potential respondents
were made until each age group included 150–200 participants. The final number
of participants was 736.
The interview guide included various scales and instruments to obtain information
about the participants’ visual impairment, their use of assistive devices, experiences
with disasters and other events involving a threat to life or integrity, as well as
matters of loneliness, coping and mental health. We used the diagnostic guidelines
of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to categorize
whether respondents fulfilled the criteria of posttraumatic stress disorder (PTSD)
or depression (American Psychiatric Association, 2013).
Trauma exposure
The participants were asked about their experiences with adverse life events spec-
ified from a list of 18 potentially traumatic events. About 80% of the participants
reported one or more adverse life-events experienced during their lives, men and
women to a similar degree. The most commonly reported adverse events were
illness or injury causing vision loss (36%), life-threatening illness or injury (35%),
and transportation accidents (32%). Fewer people had experienced natural disasters
(12%), or fire or explosions (20%).
There were some differences in the nature of the adverse events experienced by
men and women. Men were exposed to illness or injury causing vision loss to a
greater extent than women. Women were more often exposed to sexual assault and
other unwanted or uncomfortable sexual experiences than men.
Posttraumatic stress disorder
Posttraumatic stress disorder (PTSD) is a mental disorder that may develop after
exposure to exceptionally threatening or horrifying events. PTSD can occur after a
single traumatic event or from prolonged exposure to trauma.
If reporting more than one event, respondents identified their worst event, i.e. the
event that currently bothered them the most. Respondents were asked whether the
event involved accidental or violent death or danger to life, serious injury, or sexual
violence. They had to give a positive answer to fulfil the threat-criterion of PTSD.
The criteria for current PTSD were fulfilled by 12% of the participants. The prev-
alence was higher in women (14%) than in men (9%), and higher in younger age
groups than in the older. Illness or injury causing vision loss was the most common
event causing PTSD in men. For women, sexual assault, physical assault, and vision
loss were the most common events causing PTSD. The prevalence of PTSD was
considerably higher than in the general population of Western countries, sug-
gesting that blind and visually impaired people represent a high-risk population.
Disasters or large-scale accidents appear to be a minor cause of adverse mental
health in this population, as we found only one case of current PTSD (0.3%) among
people who reported that a natural disaster, fire or explosion was their worst event.
On the other hand, our findings indicate major challenges related to the mental
health consequences of injury or illness causing vision loss, and physical and sexual
assaults.
Depression
Prevalence rates of major depression were 9% in men and 12% in women, and
higher in younger age groups than in the older. The prevalence rates of major
depression were higher in our study population than in the general population,
suggesting a minority at high risk for reduced mental health.
This was even clearer when we examined the prevalence of dysthymia, a chronic
depression that entails a person being depressed on most days for the last two
Visual impairments • 87
years. Prevalence rates of dysthymia were 16% in men and 23% in women, com-
pared to the 1–3% prevalence rate in the general population.
Two factors were strongly associated with depression and dysthymia: first and
foremost the perception of loneliness, and secondly the experience of being the
victim of bullying. Both may be causal factors in the development of depression,
and since both occurred relatively frequently in this data material, they deserve to
be elaborated on.
Loneliness
The interview-guide included three questions about loneliness, i.e. how often the
responder felt lack of companionship, felt left out, or felt isolated from others.
Often feeling lack of companionship was reported by 21% of the responders, and
some of the time by 39%. Often feeling left out was reported by 12%, and often
feeling isolated from others by 13%. There were no differences across gender or
age groups. The highest levels of loneliness were reported by individuals who had
other functional disabilities in addition to their visual impairment and by people
who had experienced being victims of bullying.
Bullying
The interview also included three questions about bullying; whether the respond-
ent had ever been a victim of bullying, whether it had happened during the last 6
months, and whether bullying was related to the visual impairment. Bullying expe-
rienced at any point in life was reported by 42% of the respondents, and bullying
during last 6 months by 8%. Of those who experienced bullying, 65% reported that
the bullying had been mainly (53%) or partly (12%) related to their visual impair-
ment. There were no differences between men and women. Younger people had
experienced more bullying than the elderly. Individuals with other functional
disabilities in addition to visual impairment had been exposed to more bullying
than others.
Referral to psychologist
During the first part of the data collection (n = 315), we discovered that there was
a need for psychological follow-up for some participants. Therefore, the remain-
ing participants (n = 421) were offered psychological assistance. Of the 421 who
received the offer, 45 (11%) wanted a consultation with a psychologist. Desire
for psychological help was associated with loneliness and previous exposure to
traumatic events.
A recurring theme of the consultations was minority stress and the struggle to
handle stigma that was internalized in many cases. Other important themes were
feelings of marginalization and that people had their basic rights violated. Some
described living with visual impairment as entailing a feeling of captivity and anxi-
ety, whereas others expressed difficulty sleeping due to fears of nightly intruders.
Use of assistive devices and personal assistance
Respondents used assistive devices and personal assistance to varying degrees;

35% used a white cane, 13% a guide dog, 12% used GPS, 52% took advantage of
personal transport, and 28% of a companion. Of those who reported that they did
not use a white cane, 15% thought they would be more mobile if they used one. It
is worth noting that they had higher levels of loneliness and depression than other
respondents. Similarly, a considerable proportion of non-users thought they would
be more mobile if they used a guide dog (16%), GPS (29%), personal transport (36%)
or a companion (34%). In general, these individuals experienced more loneliness
and depression than others.
The same was true for the feeling of safety. Among non-users there were many
who believed that they would be safer if they used a white cane (28%), guide dog
(25%), GPS (26%), personal transport (33%) or a companion (40%). Higher levels of
loneliness and depression were also commonly present among these.
Lack of use was not necessarily a matter of access. For example, half or those
who thought they would be more mobile or safer if they used personal transport
reported that they had easy access to such transport without making use of it.
Similarly, a majority of those who thought they would be more mobile or safer if
they used a white cane reported that they had access to using it if they wanted. It
appears that inadequate use of assistive devices and personal assistance may result
in loneliness and depression, but the reverse causality may also apply.
Implications and recommendations
The current research project clearly shows that people with visual impairment are
at risk for reduced mental health. A significant proportion develops mental health
problems such as PTSD and depression. The most common causes of PTSD in both
males and females were injury or illness causing vision loss, and additionally for
women, physical and sexual assaults.
The mental strain caused by vision loss appears to be of high impact. The vision
loss can occur abruptly, but may also develop gradually over a long period, with the
associated stress of not knowing how the loss of vision will progress. The elevated
risk of mental health adversities in individuals with visual impairments needs to
be recognized and appropriate preventative actions taken – e. g. providing infor-
mation to at-risk visually impaired individuals and offering them mental health
examinations and follow-up by mental health care professionals. Furthermore, it is
important the ophthalmologists and others who face people with vision loss have a
low threshold for referral.
The relatively frequent reports of physical and sexual assaults on visually impaired
women suggest a group at high risk of serious abuse and subsequent psychological
reactions. This finding emphasizes the need for preventive measures as well as
professional assistance when such events occur.
Disasters and large-scale accidents appear to be a minor cause of mental health

adversities in visually impaired people. Rather, people with visual impairment have
a greater susceptibility to a variety of hazards and potential threats in daily life,
resulting in a higher risk of stress reactions, withdrawal and social isolation. This
calls for emphasis on safety procedures in everyday life and universal design in
public spaces.
At an individual level, disasters and large-scale accidents require the same

approaches used in everyday accidents. The consequences for the individual
rarely depend on whether there are few or many people who are affected at the
same time. Psychosocial first aid and aftercare for visually impaired people should
include focusing on predictability and adequate information to prepare for coping
and self-efficacy. Professionals should be aware of the need for independence and
self-reliance.
The research findings show that visually impaired people are at higher risk of lone-
liness and depressive disorders. Loneliness and depression can be consequences of
social withdrawal or inadequate social integration. Coping in social contexts can be
more challenging with visual impairment, and people with visual impairment may
be more easily left out and isolated from others. Social integration should therefore
be a main objective in promoting living conditions for people with visual impair-
ment, regardless of when in life vision loss occurs.
The research findings also show that visually impaired people are at high risk of
being bullied, and that bullying may be a possible cause of loneliness and depres-
sion. People with other disabilities in addition to visual impairment were at an
even higher risk. It is well known that being different in one way or another makes
you more vulnerable to sanctions and exclusions. Bullying is often subtle and
not always easy to address. Bullying may include intimidation or mimicking the
disability, or more subtle forms of exclusion. For example, exclusion and alienation
might result from people speaking to others instead of directly to the visually
impaired person; from underestimating a visually impaired individual due to prej-
udices; or from leaving them out of social events. In many ways, subtle forms of
bullying are like a glass ceiling effect: an invisible, subtle barrier that prevents some
individuals from developing and participating in society on equal terms.
Visually impaired and blind individuals should have the same access to mental
health services as the rest of the population. Our survey highlights an unmet
need for psychological treatment in this minority group which could have several
explanations. First, there is a lack of knowledge among health personnel about the
mental health adversities associated with visual impairment. Second, people with
visual impairment may have a higher threshold before they seek help compared to
individuals without impairments. And third, visually impaired individuals might
be reluctant to seek help due to a desire for self-reliance and to avoid being a
“victim”. Increased awareness of mental health adversities and facilitation of health
care services for people with visual impairment should be addressed by health care
authorities and user organizations in collaboration.
Some do not use assistive devices such as a white cane, guide dog or GPS, or per-
sonal transport or assistance although they had access to them, and also believed
that using them would make them safer and more mobile. It is worth noting that
reluctance to use assistive devices or personal assistance is associated with more
loneliness. There are thus good reasons to encourage visually impaired people
to use assistive devices and personal assistance in cases where this can increase
mobility and safety. Sometimes it might be a matter of overcoming fear of being
labelled, or fear of being a burden. Awareness about this is useful both for the
individual user and for the attitudes of the general population.
References
American Psychiatric Association. (2013): Diagnostic and statistical manual of men-

tal disorders, fifth edition. Arlington, VA: American Psychiatric Association
Cattaneo, Z., & Vecchi, T. (2011): Blind vision: The neuroscience of visual impairment.
London, UK: MIT Press
Colenbrander, A. (2010): Assessment of functional vision and its rehabilitation. Acta

Ophthalmologica, 88(2), 163–73
Pascolini, D. & Mariotti, S. P. (2011): Global estimates of visual impairment: 2010.
British Journal of Ophthalmology, 96, 614–18
Saur, R., Hansen, M. B., Jansen, A. & Heir, T. (2017): Visually impaired individuals,
safety perceptions and traumatic events: A qualitative study of hazards, reactions and
coping. Disability and Rehabilitation, 39(7), 691–696
Shaar, K. H. (2013): Severe war trauma and post-traumatic stress disorder in ado-
lescents with sensory impairments: A cross-sectional study. Health Psychology
Research, 1(2), 69–73
World Health Organization. (August 2014): Visual impairment and blindness. Fact
Sheet No. 1512 [Report]. http://www.who.int/mediacentre/factsheets/fs282/en/
6.2 Recommendations for the blind and visually impaired people
The following recommendations are based on the findings of a qualitative study

carried out in the first EUNAD project (2013–2014) and the population study
carried out in the EUNAD-IP project (2016–2017).
The recommendations refer to exposures to, prevention and coping with traumatic
events, as well as promotion of psychological health and wellbeing.
Recommendations are subdivided under the headings “General recommen-

dations”, “Emergency preparedness”, “Emergency response” and “Psychosocial
aftercare”.
The Norwegian Centre for Violence and Traumatic Stress Studies was the imple-
menting institution.
6.2.1 General recommendations
• “Nothing about us without co-operating with us” is essential. Contact and

cooperation with user organizations to ensure user participation are essential
and should be the foundation for developing recommendations for this group.
• Establish appropriate measures to ensure access, on an equal basis with others,

to the physical environment, to information and communications, including
information and communications technologies and systems, and to other facil-
ities and services open to or provided for the public.
• Individuals with visual impairment constitute a heterogeneous group. The abil-

ity to orientate by vision varies. Being visually impaired varies from mild vision
loss to blindness and from progressive eye diseases to established vision loss.
• Universal design in public spaces is essential and represents recommendations

for an environment that is safe and inclusive for persons who are blind and
partially sighted. Universal design implies:
• The design of the environment should be useful to people with diverse abilities
and accommodate a wide range of individual preferences and abilities.
• Simple and intuitive use: the design should be easy to understand and use,
regardless of the user’s experience, knowledge, language skills, or current con-
centration level.
• Perceptible information: the design must communicate necessary information

effectively to the user, regardless of ambient conditions or the user’s sensory
abilities.
• Preparedness: the design should minimize hazards and the adverse conse-
quences of accidental or unintended actions, and it must be possible to use the
design efficiently, comfortably and with minimum fatigue.
• The foundation for emergency preparedness lies in universal design. This is the
basic precondition toward facilitating a comfortable and accessible environ-
ment for persons who are visually impaired.
• Visually impaired and blind individuals should be educated in disaster pre-

paredness and first aid (for instance via user organizations). All measures that
enhance self-efficacy and mobility are essential in preparedness.
• Adequate information about pre-event emergency planning information

should be available in accessible formats, i.e. how to evacuate, where to get first
aid training and assistance, what should you have accessible at home.
• Information about the rights of people with visual impairment in case of emer-
gency should be disseminated thorough alternative non-visual channels.
• Concrete eliminations of hazards in public spaces, workplaces and at home may

include:
• Removing rugs and floor coverings, taping down or removing electrical cords
from pathways, and removing large pieces of furniture from the main traffic
areas.
• Placing drinking fountains and fire extinguishers along one wall only through-
out hallways allows individuals who are visually impaired to trail the other wall
without encountering obstacles.
• Providing braille signage and marking emergency exits clearly. Using high con-
trast and adequate lightning conditions in order to help people find their way
out of buildings.
6.2.3.1 Psychological first aid
The same established principles for emergency response and psychosocial first aid
must be applied for all population groups. For visually impaired and blind individ-
uals, the following should be taken into consideration:
• Ensure predictability: communicate clearly what has happened and the order of
what is going to happen next.
• Identify your role when approaching a person with visual impairment, and
touch their shoulder. Place the person next to the wall, and describe the setting.
Inform them when you leave.
• When accompanying a person who is visually impaired or blind, the most

common companion techniques should be applied: offer to assist the person by
letting the person hold your elbow.
• Offer your assistance, listen, and then assist.
• If possible, address people who are blind or have low vision by their names so
they know you are speaking to them.
• Ask people who are blind or have low vision what they want or need. Do not
direct questions through their companion.
6.2.3.2 Psychosocial aftercare
There may be higher thresholds to the access of mental health services for people
with visual impairment resulting in an unmet need for psychological treatment in
this group.
• There is a need for increased knowledge among health personnel about the
mental health adversities associated with visual impairment.
• Increasing awareness of mental health adversities and facilitating mental health

care services for visually impaired individuals should be addressed by health
care authorities and user organizations in collaboration.
• Functional impairment in addition to vision loss may imply higher risk for
mental health adversities.
• Isolation and bullying increase the risk for mental health adversities in blind
and visually impaired individuals.
Intellectual disabilities, 7
dementia and autistic
spectrum disorder
Barbara Juen, Alexander Kreh,

Michael Lindenthal, Priya–Lena Riedel
Hedvika Boukalová, David Čáp,

Simona Hoskovcová, Štěpán Vymětal
Robert Bering, Fernanda Heinke, Lena Richter

The most common mental and cognitive disorders are:
• Intellectual disability – primarily arrested or incomplete mental development;

it influences all cognitive components (cognition, memory, speech; sometimes
also locomotion and social interaction).
• Dementia – acquired reduction or loss of cognitive capacity, slower mental

pace, and problems in remembering, maintaining and recalling information,
disordered judgment and decision making, problems with planning, declining
emotional control and self-control, reduced adaptability, behavioural disorder,
cognitive deficit. Mostly occurs in old age.
• Autism – social interaction disorder and restricted, repetitive activities and

interests. Autistic spectrum disorder affects motion, emotion, will, cognitive
functioning and speech. It impacts personality and also the ability to adapt.
• Disorder of cognitive functions – resulting from other mental disorders (schiz-

ophrenia, mood disorder, neuroticism, use of psychoactive drugs).
In practice the disorders mentioned are very often combined with other difficulties
including motion disorders or hearing and visual disorders.
Risks facing target groups
• Higher vulnerability – intellectual disability has a strong influence on how per-

sons with a cognitive disorder perceive and understand information from the
outside world, how they cope with a stress situation/disaster and recover after
the experience.
• Reduced adaptation to new conditions – especially with sudden unexpected

events or when changes occur
• Reluctance to be evacuated, distrust of strangers

Intellectual disabilities, dementia and autistic spectrum disorder • 99
• Clients living by themselves are difficult to identify – so are their needs
• Difficulties in communication, limited understanding of instructions
Specific difficulties of older people
• Loss of cognitive functions
• Higher risk of injury (bone fracture etc.)
• Reduced mobility and efficiency
• Changes in thermoregulation (less effective in adapting to weather changes)
• Reduced immunity (propensity to diseases)
• Lower stress tolerance
• In case of need to leave their home, they experience powerful distress (in a
change of environment, they are torn out of their social network)
7.1 Literature analysis on people with intellectual disabilities
Hedvika Boukalová, David Čáp, Simona Hoskovcová, Barbara Juen,

Alexander Kreh, Michael Lindenthal, Štěpán Vymětal
The analysis about needs of people with intellectual disabilities was mainly carried
out from April to September 2016. The research analysis was limited by the very
low number of studies focused on the topic of mentally disabled persons in disas-
ters. The same applies to the analysis of guidelines and handbooks. A first step was
the identification and mapping of research findings, guidelines and handbooks,
practice examples and tools to provide an overview of existing knowledge about
the special needs of people with intellectual disabilities and existing recommenda-
tions and training materials for experts.
With regard to intellectual disabilities we can see that due to the higher prevalence
of (prior) traumatization in people with mental disabilities, disasters/emergencies
can cause re-traumatization or arouse strong feelings of helplessness. People with
mental disabilities have a higher need of support and care and an increased risk of
long term complications. One characteristic of persons with intellectual disabilities
relates to the awareness of danger which can be limited or absent; dangerous situa-
tions may be interpreted as meaning that the person her-/himself was responsible
for the danger (Greenspan, Switzky, & Woods, 2011). There is also a high risk that
stimuli are misunderstood, therefore an action may be inappropriate in a particular
situation (e. g. fear when facing firefighters). They often pay attention to irrelevant
stimuli, for example concentrating on the blue light instead of on emergency
alerts. Generally people with intellectual disabilities show stress reactions similar
to the reactions of people without disabilities in disasters and emergencies but they
might be more intense and they have different coping strategies. In some cases
persons with intellectual disabilities may present epileptic seizures, cardiovascular
problems, incontinence, a heightened need for attention, self-harming behaviour,
fear and defensiveness towards physical proximity and/or aggravation of exist-
ing behavioural problems (Irblich, 2006a, 2006b; Irblich & Blumenschein, 2011).
Trauma reactions specific to this population include stereotypical behaviours,
challenging behaviours, and reduced self-care (Wigham, Hatton, & Taylor, 2011).
Psychological problems or post-traumatic stress disorder are often not identified

in people with mental disabilities. People with intellectual impairments and people
without disabilities often show similar grief reactions. However, reactions may
be misinterpreted. Specific tests for improved identification of PTSD exist which
appear to have a good level of reliability for individuals with intellectual disabilities
(Hall, Jobson, & Langdon, 2014). People with mental disabilities who have experi-
enced a traumatic event may require special psychological care. Trained mental
health professionals can help them in identifying and coping with the trauma
(Ballan & Sormanti, 2006).
• 140 studies (37 of which are specifically about people with intellectual
disability)
• 76 guidelines and handbooks (10 of which are about people with intellectual
disability)
• 54 tools (6 of which are for people with intellectual disability)
• 13 practice examples (none of which is specifically for people with intellectual

disability)
The full list of resources is published on the EUNAD webpage www.eunad-info.eu.
7.1.1 Definitions and terms: General learning disability/intellectual disability/

mental retardation
The most influential definition is that of the American Association on Mental

Retardation (1992), which defines mental retardation as involving significant
impairment in intellectual functioning with significant impairment of at least two
areas of adaptive functioning and age of onset before the age of 18.
The terms most often in use are general learning disability, intellectual disability/
impairment, and mental retardation. They refer to generalized neurodevelop-
mental disorder, which includes impaired intellectual and adaptive functioning.
An intelligence score below 70 and difficulties in managing autonomous every-
day living are generally accepted as characterising the impairment. The specific
behavioural problems represent a developmental delay in childhood and adoles-
cence regarding intellectual and social functioning. Persons with mild learning
disability may be able to function at a semi-independent level. Nevertheless, they
require assistance and support throughout their lives. Persons with severe forms of
intellectual disabilities depend heavily on the health care system.
“Various terms are used in the West for mental retardation, including mental sub-
normality, mental deficiency, feeble mindedness (late 19 Century term), and mental
disability. The American Psychiatric Association’s Diagnostic and Statistical Manual
of Mental Disorders, (DSM-IV-TR, 2000) defines MR as a central nervous system
dysfunction producing an IQ below 70; this results in significant deficiencies in two
or more life skills, such as self-direction, academic skills, social skills, communication,
health, and work. Five subdivisions are identified: mild (IQ 50/55 to 69), moderate
(35/40–50/55), severe (20/25–35/40), profound (under 30/25) and severity unspecified
(suspected, but not testable).” (Greydanus & Pratt, 2005, p. 859).
Syndromes associated with mental retardation include for example autism,

cerebral palsy, Down syndrome, fragile X syndrome, myelomeningocele, neurofi-
bromatosis, Prader Willi syndrome, velocardiofacial syndrome, Williams Syn-
drome.
In our project, we focus on learning disabilities in general. Two forms of mental

disabilities are focused upon separately because of their specific characteristics
with regard to emergency situations.
Autism Spectrum disorder
The autism spectrum disorder (ASD) represents a group of developmental impair-

ments. Symptoms of ASD may persist to adulthood. Ratings estimate that 1% of
children are affected with autism spectrum disorder (Kogan et al., 2009) with an
imbalance between boys and girls. Autistic spectrum disorders occur four to five
times more frequently in boys (CDC, 2010). The shape and severity of the corre-
sponding symptoms vary between affected individuals. Individuals with autism
show impairments in three different domains:
• Social interaction (restrictions to interpretation of nonverbal communication,

limited ability to build up relationships with peers, limited interest in sharing
emotions with others)
• Communication (late onset or no verbal communication and no compensation

by gestures, or no ability to engage in conversation with others, stereotypical
repetitive language)
• Behaviour (often narrow, repetitive patterns of behaviour)
DSM-V subsumes under the term autism spectrum disorder the following
subtypes: Autistic disorder, Asperger’s disorder, Rett syndrome and childhood
disintegrative disorder. The manual offers three levels of severity: Requiring

support (Level 1), requiring substantial support (Level 2) and requiring very sub-
stantial support (Level 3). These levels may serve to design individualized treatment
plans. Interventions aim at the improvement of speech, language, social skills and
behavioural aspects.
Prevalence rates of people with intellectual/learning impairments in Europe and

worldwide
In Europe individuals affected by intellectual disability mostly attend special

institutions like kindergartens or schools for people with special needs. Children
with intellectual problems often live with their families whereas many adults with
intellectual disabilities stay in housing facilities for individuals with disabilities
(Braddock, Emerson, Felce, & Stancliffe, 2001). Persons with mental disabilities
generally need support in daily activities. The worse the impact of the disability on
the person, the less they are able to take part in demanding activities. This may lead
to helplessness in self-care (Nota, Ferrari, Soresi, & Wehmeyer, 2007).
People with intellectual disabilities are amongst the most disadvantaged social
groups in Europe (European Intellectual Disability Network, 2003). As traditional
patterns of care tend to institutionalize these people, social isolation and exclusion
are frequent. Some European countries have therefore started to increase social
inclusion of persons with intellectual disabilities. The common trend goes to
community living and away from institutionalization.
Prevalence is less than 1% in all European countries. Epidemiological studies sug-

gest that 3 to 4 per 1,000 people of all ages suffer from severe intellectual disability.
In the 28 countries of the European Union this is between 1.5 and 2 million people.
In the case of mild intellectual disability, studies estimate about 2.3 to 2.7 million
affected people in the EU.
Global prevalence studies show that while among adults the rates vary between
3–6/1000, among children the rates are between 3–14/1000. Particularly among
children, the rates vary a lot depending on diagnostic systems, the age of the
child, and the source of administrative data. For example, using IQ-based clinical
guidelines would give higher estimates than those based on more comprehen-
sive adaptive behaviour and psychological assessments (King et al., 2009). A 2011
meta-analysis of international studies found the prevalence of individuals across
the life span to be 1.04% (Maulik, Mascarenhas, Mathers, Dua, & Saxena, 2011). A
follow-up meta-analysis of international studies, extending the work of Maulik
et al. (2011), found the ID prevalence of children/adolescents and adults to range

from .05 to 1.55% (McKenzie, Milton, Smith & Ouellette-Kuntz, 2016).
(see: http://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942540&sec-
tion=Incidence_and_Prevalence)
Dementia
When examining the topic of reactions and needs of people with mental disabil-
ities in emergencies and disasters we must also include another group, namely
people with dementia.
Dementia is a disorder caused by brain damage that increases with age.
ICD 10 (10th Revision) labels four criteria that must be fulfilled for a diagnosis of
dementia:
1. A memory decrease which leads to problems in everyday life activities or

makes independent living difficult or impossible
2. A decline in cognitive abilities like thinking, planning and organizing everyday

life. This leads to problems or the inability to live independently.
3. At the beginning, orientation in space and time remains possible for the
affected. At later stages, orientation is more and more impaired.
4. An impairment in emotional control, motivation or changing social behav-

iours. This manifests itself in emotional irritability, apathy or impairments in
social behaviour like eating, dressing and interaction.
The Clinical Dementia Rating (Berg, 1988) creates 5 categories describing the
severity of dementia
It rates the severity from a range from 0 to 3.
• No dementia (CDR = 0): The person has no decline in cognitive function and
memory. The person is able to live completely independently, solves everyday
problems well and is fully orientated.
• Questionable dementia (CDR = 0.5): Slight impairment in managing everyday

life and activities. The person is fully orientated apart from slight difficulties
with time contexts. Constant mild forgetfulness and partial recall of events are
characteristic.
• Mild dementia (CDR = 1): Independent living and difficult hobbies and tasks are
no longer possible. The person is no longer independent and needs encourage-
ment and support from others. At this stage, affected persons have moderate
problems with cognitive tasks like problem-solving. Memory problems con-
cerning recent events occur. The forgetfulness impacts everyday activities.
• Moderate dementia (CDR = 2): During this stage of dementia, memory is already
severely affected. The person can only remember profoundly processed mate-
rial. Recall of recent events and declarative memory are impaired. In most situ-
ations, the person is disoriented in time and often in place. The person experi-
ences severe problems with cognitive tasks and their social judgement ability
decreases. Affected persons manage simple chores and his or her interests are
restricted. At this point assistance is needed for tasks like dressing, hygiene and
handling of belongings.
• Severe Dementia (CDR = 3): This subtype is characterized by a severe memory

loss; only fragments of autobiographical memory remain. The person is not
oriented in time and space. They can no longer use cognitive functions like
judgment or problem solving. People with severe dementia need extensive help
with personal care and are frequently incontinent.
There are different diseases with dementia symptoms. The most common is
Alzheimer’s disease, followed by vascular dementia, mixed dementia and fron-
to-temporal dementia. Less common causes of dementia include Parkinson’s
disease, severe alcohol abuse, Creutzfeldt-Jakob disease, Huntington’s disease,
Pick’s disease.
Prevalence of dementia in Europe and worldwide
The risk for developing dementia increases rapidly with advancing age. Reviews
(Jorm et al., 1987; Hofman et al., 1991; Ritchie et al., 1992) have shown that the
prevalence rate for dementia lies between 0.7–1% in persons between 60 and 64.
This rate increases with advancing age. People between 85-89 years have a signifi-
cantly higher risk of developing dementia. The prevalence rates lie between 16.4%
up to 23.6%. In Europe the general prevalence rate over all age groups is 1.55%. The
European Commission (2006) estimates that a total of more than 7 million people
in Europe suffer from dementia.
Looking at worldwide prevalence we see that age-standardized prevalence for

those aged 60 years varied within a narrow band of 5%–7% in most world regions,
with a higher prevalence in Latin America (8.5%), and a distinctly lower prevalence
in the four sub-Saharan African regions (2%–4%). It was estimated that 35.6 million
people lived with dementia worldwide in 2010, with numbers expected to almost
double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050. In 2010,
58% of all people with dementia lived in countries with low or middle incomes,
with this proportion anticipated to rise to 63% in 2030 and 71% in 2050 (Prince et
al., 2013, p. 64).
7.1.2 Persons with learning/intellectual disabilities in emergencies and disasters
According to some prejudices people with disabilities do not often experience

emergencies, have no conscious awareness of emergencies and do not talk about
traumatic memories. It is also claimed that helpers are well prepared to deal with
people with intellectual disabilities in cases of emergency. Furthermore it is often
stated that emergency preparedness would only foster a feeling of insecurity
among people with intellectual and learning disabilities. However, studies have
shown that emergencies quite often also involve people with learning disabilities
(Stough & Mayhorn, 2013). Additionally, people with learning disabilities do con-
sciously experience emergencies, and even in cases where it cannot be established
that they consciously experience emergencies, it cannot be concluded that the
traumatic event has no consequences for them (Ballan & Sormanti, 2006). Studies
have also shown that emergency helpers are not well prepared for the specific
needs of people with disabilities, whereas caregivers of people with intellectual dis-
abilities often do not know how to deal with traumatic events or disasters. Finally,
it cannot be concluded that emergency preparedness automatically makes people
feel insecure because it depends to a great extent on how (programs on) prevention
or preparedness are conducted (Mevissen & de Jongh, 2010).
Persons with intellectual disabilities are defined as having an IQ < 70 and they
often have difficulties in acquiring knowledge and verbal comprehension. They
may face additional limitations, such as requiring a concrete, action-guided intro-
duction to new circumstances and may be unable to live independently (American
Psychiatric Association, 2013). Adults with intellectual disabilities often have a car-
egiver, provided for by governmental legislation. The performance of people with
intellectual and learning disabilities depends on a well-structured and well-known
environment, well-known caregivers and practiced action steps. In unknown situa-
tions, therefore, persons with intellectual disabilities react with a higher degree of
helplessness and uncertainty (Wüllenweber, Muehl & Theunissen, 2006).
Prevalence of traumatization among persons with intellectual disabilities
Research also shows that there is a higher prevalence of (prior) traumatization in

persons with intellectual and learning disabilities because of prior medical inter-
ventions, abuse by family or institutions, risk of physical abuse in public, high risk
of accidents influenced by a lower awareness of dangerous situations and experi-
ences of loss (e. g. of caregivers) which can be particularly threatening because they
are heavily dependent on caregivers (Irblich, 2006a, 2006b; Irblich & Blumenschein,
2011). According to Greydanus and Pratt (2005), the most difficult group to manage
and support are individuals who are not mentally retarded but have below-av-
erage levels of intellectual function (IQ scores 70–85). In adolescence, this group
is particularly at risk of victimization: young women do not have the intellectual
capacity to learn how to prevent rape while young men often get into trouble with
authorities because they are easily led astray by their cognitively superior peers
(Greydanus & Prat, 2005).
How do people with mental disabilities experience disasters/emergencies?
Due to the higher prevalence of (prior) traumatization in people with intellectual

disabilities, disasters/emergencies can produce a re-traumatization or give them
a strong feeling of helplessness. They have a greater need of help and care and
an increased risk of long term complications. One characteristic of persons with
intellectual disabilities relates to the awareness of danger which can be delayed or
absent; dangerous situations might also be interpreted as meaning that the person
her-/himself was responsible for the danger (Greenspan, Switzky & Woods, 2011).
In some cases persons with intellectual disabilities may show severe somatic stress
reactions like epileptic seizures, spasticity, cardiovascular problems, incontinence,
heightened need for attention, self-harming behaviour, fear and defensiveness
against physical proximity and/or aggravation of existing behavioural problems
(Irblich, 2006a, 2006b; Irblich & Blumenschein, 2011).
Challenges for people with mental disabilities in disasters
According to Stough (2015) disaster planning related to people with intellectual

disability needs to take into account that people with intellectual impairments (1)
experience disproportionate risk in disaster situations, (2) are often excluded from
relief processes and are disadvantaged in disaster support situations, (3) may need
specialized disability-related supports, (4) often need assistive technology and
special rehabilitative services, (5) rely on their family and community networks
as important supports in disaster situations, and (6) need special attention during
recovery and rebuilding (see also World Report on disability (WHO, 2011))
Thus, “People with intellectual disabilities are more likely to need additional assis-
tance during evacuation, experience more tangible losses during disaster, and require
more intensive support in the recovery phase following disaster. Enabling access to
mainstream systems and services, improving human resource capacity, and provid-
ing adequate funding for recovery and disaster mitigation are strategies to increase
disaster resilience for individuals with intellectual disabilities.” (Stough, 2015, p. 138).
The report mentions that Costa Rica is one country that has designed emergency
disaster management policies and incorporated disability rights policies that cut
across governmental functions and promote interagency cooperation (Stough,
2015).
“Having such policy structures and legislative supports is advantageous for people
with intellectual disability, whose support needs often cut across different functional
areas.” (Stough, 2015, p. 138).
People with dementia in emergencies and disasters
Older people often have a variety of impairments. Comorbidity is rather high. Thus,
sensory, physical and intellectual impairment are very often combined in older
people. As we showed in another EU project (PrepAge2) older people face a great
variety of challenges in disaster situations.
The challenges and needs of older people in disasters arise around the following
topics. They are connected to older people’s vulnerabilities, their low social status
and a generally low level of preparedness in organisations caring for older people
(PrepAge des research report, 2014, p. 37).
• Invisibility of older people
– Neglect of vulnerability factors and intersectionality
– Lack of identification and data on vulnerable older people
2 ECHO/SUB/2013/661043 PrepAge enhancing the preparedness of older people in disasters

2014–2016, http://prepage.eu/en/
– Exclusion and insufficient policies and laws for older people in disasters
• Discrimination and lack of protection
– Marginalization of older people
– Risk of abuse of older people
• Lack of financial support
– Economic neglect of older people in disasters
– Older people’s lack of resources before and after disaster
– Barriers to receiving and applying for support
• Need for additional health resources and support
– Disruption of infrastructure
– Unnecessary institutionalization
– Lack of medical resources for older people
– Higher risk of injury, mortality and morbidity in older people
• Need for adequate facilities and accessible distribution points
– Inaccessible hygiene and health facilities, inadequate shelters
– Limited access to distribution
• Need for adequate nutrition of older people
• Higher risk of stress-related problems
• Difficulties in evacuation
– Lack of means (transportation etc.) for older people
– Lack of understanding for special needs (e. g. pets) of older people

– Lack of concepts (shelter, transport etc.) for evacuation of older people
• Lack of adequate warning systems for older people
• Low level of preparedness among older people and agencies caring for older
people
Legal status of people with intellectual impairment
In principal the legal rights for people with intellectual impairment are the same
as for people without impairments. Nevertheless, people with severe intellectual
impairments are considered unable to execute these rights and therefore have
a legal guardian (often a family member). A formal representative can also be
appointed by court. Most services believe that if people are able to give consent
to living conditions and working conditions they should be allowed to choose
the kind of support/care that they want but mostly they are not given a choice. In
particular, people with challenging behaviour, people with severe intellectual dis-
ability and people with autism live under very restricted conditions. This includes
restricted choice about medical treatment and support in emergency and disaster
situations.
References
Berg, L. (1988): Mild senile dementia of the Alzheimer type: diagnostic criteria and
natural history. Mt. Sinai J. Med.pp 55, 87–96
Braddock, D., Emerson, E., Felce, D. & Stancliffe, R. J. (2001): Living circumstances
of children and adults with mental retardation or developmental disabilities in the
United States, Canada, England and Wales, and Australia. Mental Retardation and
Developmental Disabilities Research Reviews, 7(2), 115–121. www.ncbi.nlm.nih.
gov/pubmed/11389566
Greenspan, S., Switzky, H. N. & Woods, G. W. (2011): Intelligence involves risk-aware-

ness and intellectual disability involves risk-unawareness: Implications of a theory of
common sense. Journal of Intellectual and Developmental Disability, 36(4), 246–257.
www.ncbi.nlm.nih.gov/pubmed/22050455
Greydanus, D. E. & Pratt, H. D. (2005): Syndromes and disorders associated with

mental retardation. Indian journal of pediatrics, 72(10), 859–864
Hall, J. C., Jobson, L. & Langdon, P. E. (2014): Measuring symptoms of post-traumatic

stress disorder in people with intellectual disabilities: The development and psycho-
metric properties of the Impact of Event Scale-Intellectual Disabilities (IES-IDs). Brit-
ish Journal of Clinical Psychology, 53(3), 315–332. http://doi.org/10.1111/bjc.12048
Hofman, A., Rocca, W. A., Brayne, C., Breteler, M. M. B., Clarke, M., Cooper, B.,
Copeland, J. R. M., Dartigues, J. F., da Silva Droux, A. & Hagnell, O. et al (1991): The
prevalence of dementia in Europe: a collaborative study of 1980–1990 findings. Int. J.
Epidemiol. 20, 736–748
Irblich, D. (2006a): Traumafolgestörungen bei Menschen mit geistiger Behinderung.

In: Klauß, Theo (Eds.)(2006). Geistige Behinderung – Psychologische Perspektiven.
Heidelberg: Universitätsverlag Winter, 121–137
Irblich, D. (2006b): Posttraumatische Belastungsstörungen bei Menschen mit geistiger

Behinderung. In: Geistige Behinderung. Fachzeitschrift der Bundesvereinigung
Lebenshilfe für Menschen mit geistiger Behinderung e. V. 45. Jg., 1/06, 112–123
Irblich, D. & Blumenschein, A. (2011): Traumatisierung geistig behinderter Menschen

und pädagogische Handlungsmöglichkeiten. In: Trauma und Gewalt. Forschung und
Praxisfelder. 5. Jg., 1/11, 74–93
Jorm, A. F., Korten, A. & Henderson, A. S. (1987): The prevalence of dementia: a quan-
titative integration of the literature. Acta Psychiatr. Scand., 76, 465–479
Kogan, M. D., Blumberg, S. J., Schieve, L. A., Boyle, C. A., Perrin, J. M., Ghan-
dour, R. M., Singh, G. K., Strickland, B. B., Trevathan, E. & van Dyck, P. C. (2009):
Prevalence of parent-reported diagnosis of autism spectrum disorder among children
in the US, 2007. Pediatrics 2009, Nov, 124(5), 1395–403
Maulik, P. K., Mascarenhas, M. N., Mathers, C. D., Dua, T. & Saxena, S. (2011): Preva-
lence of intellectual disability: a meta-analysis of population-based studies. Research
on Developmental Disabilities, 2011 Mar-Apr; 32(2), 419–36. doi: 10.1016/j.
ridd.2010.12.018. Epub 2011 Jan 13
McKenzie, K., Milton, M., Smith, G. & Ouellette-Kuntz, H. (2016): Systematic Review
of the Prevalence and Incidence of Intellectual Disabilities: Current Trends and Issues.
Current Developmental Disorders Reports, June 2016, Volume 3, Issue 2, 104–115
Mevissen, L. & De Jongh, A. (2010): PTSD and its treatment in people with intellectual
disabilities: a review of the literature. Clinical Psychology Review, 2010, April, 30 (3),
308–316
Nota, L., Ferrari, L., Soresi, S. & Wehmeyer, M. (2007): Self-determination, social
abilities and the quality of life of people with intellectual disability. Journal of
Intellectual Disability Research, 51(11), 850–865. http://doi.org/10.1111/j.1365-
2788.2006.00939.x
PrepAge desk research report. (2014): www.prepAge.eu
Prince, M., Bryce, R., Albanese, E., Wimo, A., Ribeiro, W. & Ferri, C. (2013): The global
prevalence of dementia, Alzheimers & Dementia. Elsevier, 64–75
Ritchie, K., Kildea, D. & Robine, J.-M. (1992): The relationship between age and the
prevalence of senile dementia: a meta-analysis of recent data. Int. J. Epidemiol., 21,
763–769
Stough, L. M. (2015): World Report on Disability, Intellectual Disabilities, and Dis-

aster Preparedness: Costa Rica as a Case Example. Journal of Policy and Practice in
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national Journal of Mass Emergencies and Disasters, 31(3), 384–402
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on People With Intellectual Disabilities: A Systematic Review. Journal of Mental
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5864.2010.534576
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Wüllenweber, E., Muehl, H. & Theunissen, G. (2006): Pädagogik bei geistigen Behin-
derungen. Ein Handbuch für Studium und Praxis. Stuttgart: Kohlhammer
7.2.1 Needs and reactions of persons with intellectual disabilities in case of disaster
and possible supportive interventions for caregivers
Fernanda Heinke, Lena Richter, Robert Bering
Introduction
This study focussed on intellectually disabled survivors. Due to the lack of knowl-
edge about the special needs and posttraumatic reactions of people with intellec-
tual disabilities and the lack of management requirements and support structures,
it is necessary to emphasize useful information about the experiences and behav-
iour of people with intellectual disabilities in cases of disaster.
Method
A qualitative study was constructed based on the results of previous investiga-

tions and on the five essential elements of immediate and mid-term mass trauma
intervention by Hobfoll and colleagues, concerning safety, calming, sense of self-
and community efficacy, connectedness and hope (Hobfoll et al., 2007). The study
was implemented in person. Seven participants with an intellectual disability were
interviewed as well as one person with no disability. Different types of intellectual
disabilities were involved, including Down syndrome, mental retardation and
autistic spectrum disorder. Some participants were accompanied by a caregiver.
Results were evaluated by content analyses (acc. to Mayring, 2015)
Results
Our study shows that in cases of emergencies or disasters, people with intellectual
disabilities are more dependent on others than people without a disability. Their
emotions and thoughts concern fear, vulnerability, and worries about others and
themselves, so they do not differ much from those of people with no intellectual
disability. The most common reactions in emergency situations reported by
participants are looking for help, asking questions about what is happening and
getting out of the situation to rest and to avoid being in the way of helpers, so these
can take care of other affected persons. First responders in emergency settings
should provide a secure environment, be near to the person, and give explanations
about the incident and further procedure. They should also have a positive attitude
and transfer feelings of optimism. Touching the people with intellectual disabil-
ities, for example holding the hand or putting an arm around them, is advocated
by most participants but should be tested carefully. The affected people’s personal
items and relaxation techniques are helpful in creating feelings of safety, calm-
ness and reassurance, but the presence of their trusted companions is even more
helpful.
In reference to the recovery phase, i.e. the time after the disaster or crisis, par-
ticipants stated that emotions like sadness, worry, weakness and disorientation
can arise. There may also be a tendency to repress many thoughts concerning the
disaster. A need for conversations and social closeness arises. Stressful situations
or situations similar to the incident will be avoided. Professional aid can be useful
in ensuring appropriate processing of the traumatic event and emotional support.
However, therapeutic support depends on the patient’s cognitive ability and the
therapist’s knowledge about the treatment of intellectually disabled persons. The
feeling of being connected to others and having companions around them, as well
as concentrating on hobbies and retaining the familiar daily structure, encourages
the process of re-entering routines after crises and gives feelings of calmness and
safety.
Some participants reported that preventive emergency plans in residential com-

munities can provide a structured procedure in case of disaster. However, all
participants agreed that a safety advisor in every residential community or private
home is preferred. The safety advisor’s tasks should include, among other things,
informing those affected and their relatives and explaining what has happened and
what will happen, staying calm, knowing about necessary contacts and relieving
the victim by taking responsibility for the situation. Individual emergency tool
kits filled with personal items could also help to stabilize emotions after stressful
situations.
Discussion
Crisis intervention management for the intellectually disabled should be enhanced

by training first responders to impart knowledge about proper behaviours towards
people with intellectual disabilities and thus minimize traumatic consequences.
In addition, people with intellectual disabilities need more care and inclusion into
the community than others to enable them to recover from stressful incidents.
A trained safety advisor in every community containing people with intellectual
disabilities, who is able to react as efficiently as possible could therefore help
to prevent potential damage in crisis scenarios. Future implementation should
concentrate on examining more cases and using different methods such as group
surveys or discussions and interactive approaches to gain further information.
References
Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J. & Friedman, M. J. et
al. (2007): Five Essential Elements of Immediate and Mid-Term Mass Trauma Inter-
vention: Empirical Evidence. Psychiatry 70 (4), 283–315
Mayring, P. (2015, 12th edition): Qualitative Inhaltsanalyse: Grundlagen und Techni-

ken. Weinheim: Beltz
7.3 Recommendations for people with intellectual disabilities,
dementia and autistic spectrum disorder
Note: in this text we use the term “mental disability” to cover three sub-groups of
disabilities. By the term “people with mental disability” we understand people with
either intellectual disabilities, dementia or autism spectrum disorder. If we give
recommendations for a specific group, we use the specific diagnostic term.
The following recommendations are based on multiple sources. One of these is

the literature analysis of the topic, mainly using the guidelines based on research
or particular experiences. Another source were workshops with representatives of
caregivers for people with mental disability, emergency rescue services’ represent-
atives, therapists and other specialists working with the target group. They shared
their experiences and expertise and gave feedback to the information from the
literature sources. In this way they also evaluated previous results and recommen-
dations. Another source was a qualitative study carried out within the frame of the
EUNAD projects.
In the following recommendations we clearly indicate if they are meant for the
whole group of persons with “mental disability” or if they are specially focused on
only one group – people with intellectual disabilities, dementia or autistic spec-
trum disorder.
The University of Innsbruck and the Charles University in Prague were the
implementing institutions with comprehensive support from the University of
Würzburg – Department special education, especially Thomas Spaett.
The most important aspects in the prevention phase are raising awareness and
training activities:
• Raise awareness within the community for people with mental disabilities.
Community connectedness is very important, using local sources which can
support the correct reaction of people with intellectual disabilities to emer-
gency situations and efficient evacuation.
• Promote trust in the community – a bridge for communication with clients.

Clients usually trust their local organization/caregivers they are in touch with.
• Train all helpers in psychosocial support and psychological first aid for people
with mental disabilities including first responders and first aid personal. Ensure
that coercive methods are only used as the very last resort.
• Ensure that all personnel is aware of national legal regulations regarding the
use of coercive methods.
• Design emergency plans and set up intervention teams in facilities for people
with mental disabilities. Institutions/service providers that provide services to
people with specific needs through permanent or temporary accommodation
and care should have emergency aid plans for at least the first 72 hours.
• Promote local interagency cooperation/networking between different care

organizations and emergency organizations/cooperate with other organiza-
tions for people with mental disabilities.
• Implement local teams specialized in working with people with mental disabil-
ities for intervention in disasters.
• Cooperate with emergency workers including local authorities and organ-

izations to improve emergency preparedness of people with intellectual
disabilities (planning, evaluating of preparedness and knowledge, raising aware-

ness of needs and capacities of people with disabilities).
• Develop communication networks for unexpected events for people with

mental disabilities. Prepare a contact list of relatives, close persons or a list of
cooperating organisations that can give support in case of emergency.
• We recommend creating an identification bracelet (name + contact of service

provider) for each person.
• Create a list of specific reactions and needs of each person. This list should also
include a list of medication and dosage (client card in emergency form, i.e. lami-
nated A4 form, portable).
• Prepare medication to cover 14 days.
• Knowledge of evacuation plan for staff and clients is essential and should be
trained and tested at least once a year. Organize exercises for caregivers and for
people with mental disabilities. Primary caregiver – should check whether peo-
ple with intellectual disabilities are prepared for a disaster/emergency situation.
– Actively involve persons with mental disabilities in exercise and drills but
provide an environment that does not induce too much hyperarousal. If
some people with mental disabilities are considered likely to become too
stressed, exclude them from the drill but train with the rest of the group.
– For people with dementia the training may not have a positive effect. Train-
ing for helpers and caregivers may be more efficient; this in turn may lead to
a better and calmer evacuation procedure in case of emergency.
• Transport plans primarily for patients with mobility issues should be well pre-
pared in advance.
• Plan of substitute accommodation/shelter – choosing adequate (similar)

institution.
• Cooperate with media so that information is also suitable for people with men-
tal disabilities (simple language).
Advantages of involving community organizations in emergency planning
• Organizations providing daily services for people with mental disabilities

have the best awareness about their clients’ reactions needs and vulnerabili-
ties during emergency situations.
• Local organizations may or may not be connected to the state organizations

providing services primarily to certain groups of people. These organizations
know how to contact e. g. homeless people, low-income people and older
people.
• Community organizations are experts in active searching, giving recommenda-

tions, maintaining contact with groups of volunteers, and being able to provide
special services. Language and cultural sensitivity is important.
• Involving these organisations in emergency planning, preparation and training

is possible and recommended.
• Mapping and support in availability/accessibility – i.e. for people living alone

and not in institutions – can be only done in close cooperation with local
communities.
7.3.1.1 Training and preparation
Cooperation of emergency workers with local organizations:
• Provide seminars, workshops for all staff and volunteers, exchange mutual
knowledge and experience (between caregiving organisations and emergency
personnel), provide knowledge about target groups and train specific ways of
initiating communication and how to deal with people during evacuation.
• Carry out regular exercises (if possible clients should know e. g. “their” firefight-
ers and should not be afraid of them, but firefighters should also get to know
their potential “clients”) – training in the use of protective equipment, evacua-
tion etc.
• Use “Open doors days” – connecting organizations, public and emergency

workers to get to know each other but be aware that cooperation is only effec-
tive if it is long term.
• Direct experience reduces fear and prejudice in all involved parties.

Suggestions for preparing the target group
• In some cases practical training and preparation in the organizations is not pos-
sible due to the clients’ state of health. Develop other forms of exercise, but be
aware that in most cases it is possible and effective to actively include especially
people with intellectual disabilities in exercises.
• Provide a safe and understandable framework in exercises and training with

people with intellectual disability.
• Importance of individual plans – including a basic kit/package of emergency

preparedness.
• Persons with limited mobility should be supported in arranging emergency

transport plans in advance.
• Contents of kit/package:
– Identification bracelet (name, date of birth + contact of service provider or

assistant);
– List of specific individual needs of each person (name of a client, contact to

close person or assistant, actual list of medication and dosage (client card in
emergency form, i.e. laminated A4 form, portable);
– Medication in prepared dosage for 14 days.
In the response phase psychological first aid must be adapted to the skills and
needs of persons with mental disabilities.
First contact to persons with mental disabilities
• Respect the dignity and independence of people with intellectual disabilities

during an emergency: For example: Don’t treat persons with intellectual disa-
bilities like children, talk to in a manner that is appropriate to their age.
• Take into account that despite all effort some people with mental disabilities
will not be able to understand.
• According to the degree of impairment, communicate with the assistants or

staff to get needed information.
• Ensure orientation according to the degree of impairment.
• Pay attention to nonverbal signals and try to respond to these adequately.
• Explain each action you perform verbally even though there might be a lack of
speech comprehension.
• Use simple, slow, but not infantilizing language.
• Be careful in the case of physical proximity (caution: Individuals with intellec-

tual disabilities might fear medical interventions).
• Some people with intellectual disability or autistic spectrum disorder use

assistive technologies to communicate.
• Ensure that basic needs are covered and promote stress reduction:
– Assess needs depending on the degree of impairment (e. g. restricted com-

munication possibilities or obsessions with certain concerns (toy/mother).
– Permit stereotyping or automutilitative behaviour (reduction of tension and

calming down).
– Minimize additional sources of distress – for example switch off emergency

vehicle light.
• Enhance feelings of protection, safety and stabilization:
– Involve trusted individuals, familiar environment, belongings, assistive

technologies, activities; establish contact to persons of trust (parents).
– Implement security by providing distance or proximity (individual

differences).
– Promote the feeling of self-efficiency and independence as much as possible.
– Be aware that concrete and actual experience is more important than

imagination.
– Be aware of group thinking and group behaviour (calming group behaviour).
– Keep attention on dynamics and emotion transmission in a group of clients.

On the other hand, evacuation of clients in groups may give them feeling of
safety.
• Involvement of caregivers:
– In most cases caregivers are affected by the disaster themselves and

restricted in their actions; they cannot care for more individuals at the same
time. Therefore: Cooperate with caregivers, help them to help or include
other capable persons of trust.
– Support and advocate for caregivers.
– Instruct trusted people how they can help.

• Information dissemination:
– Focus on few key points and concrete information (support via gestures).
– Use clear, guided communication.
– Seek information from family members.
– Involve local caregivers and institutions.
– Ensure counselling for caregivers and facilities for persons with intellectual
impairment.
• Responding to self-harm and harm towards others:
– Pay attention to the safety and protection needs of helpers.
– Act in an effective and in the least harmful manner.
– In severe cases contact medical personnel to support with medical

treatment.
– Permit grief.
Specific communication aspects of older people with dementia
• Address clients using their names or titles (not using “grandma”, “grandpa”).
• Be active in checking for possible communication barriers and adjust your

communication.
• Calm down possible sources of noise – TV etc.
• Don’t use a loud voice, unless you are sure the client is hard of hearing.
• Respect clients’ slower pace and protect them from time stress.
• Repeat information several times and/or use writing on paper, when the infor-
mation is complicated.
Specific communication aspects of people with intellectual disabilities
• It always depends on the level and strength of the disorder. Staff and assistants
are most familiar with clients’ specifics.
• Be aware of different rules of communication! (take the whole situation into

account). There are different levels of verbal communication – they may have
trouble using “yes/no” correctly.
• Don’t underestimate clients in communication – avoid childish talk, communi-

cate with them like with adults. Avoid paternalism.
• Expect high suggestibility – people are easily influenced by others.
• Be aware of a tendency to be dependent on other people.
• Expect poor orientation in unknown environment.
• Clients may react in a “strange way”, in their own way (i. e. can react very loudly
to a very small change).
• They may ask strange questions and repeat them over and over again.
• They may talk to themselves.
• Sometimes they laugh when other people don’t.
• They use facial expressions less or in their own way.
• They may get into strange body positions.
• Very often they don’t respect communication (personal) space.
• Calm them down, explain what is going on.
• Use simple language. Avoid specialist terminology, phrases, irony etc.
• Use nonverbal communication:
– Illustrative gestures – point at body, at concrete objects etc.
– Use pictures/picture cards

• Use assistive technologies (talkers and other technical aids) if available
• Verify their understanding
• Allow more time for answering
• If they don’t understand show them what you mean or use different words or
sentences.
• Use concrete expressions and exact timing: instead of saying, “We will go for a
walk in two hours” it is better to say, “We will go for a walk after lunch”.
• Always speak about one topic/one object/one thing at a time.
• Be clear in letting the person know that the conversation is finished or that you
are leaving.
• During transport, use physical contact (holding hands) until you pass on a client
to a familiar person; it is best to involve persons the clients know!
Specific communication aspects of people with autism spectrum disorder
• They may not communicate verbally, and may not always react or react with
one word. Be aware of nonverbal signs.
• They may have trouble with the correct use of yes/no.
• They may not ask usual questions – e. g. a question that doesn’t correspond to
the person’s age or that is unusual (repeatedly asking about measures such as
height, weight, technical questions, time of city transport etc.) or asking about
the same thing over and over again.
• Conversation is often not suitable to the situation (they don’t respect social
context; do not differentiate between conversation partners).
• They very often talk to themselves.
• Inappropriate laughter with no meaning.
• Stereotypes – repeating the same words, sentences, songs, verses etc.

• Verbalism – “verbiage”, accumulation of words or sentences used incorrectly.
• Echolalia – repeating words, sentences, phrases. It may be immediate or

postponed.
• Hyperacusia – hypersensitivity to audio impulses with inappropriate reactions

(aggression – towards all around, or themselves).
• Overgeneralization of words – i.e. everything red is blood.
• Some may not be able to generalize – “a car” – they may mean only one specific
car, e. g. a toy from their childhood.
• Their talk may have a mechanical and formal sound.
• They may speak about themselves in the 3rd person (he/she/it), very small
usage of the 1st person.
• Many have difficulty in using and understanding irony or abstract expressions.
• Eye contact – they often have problems in establishing and maintaining eye
contact, looking “through” you, not stable in looking at you, looking at objects
for a very long time etc.
• Facial expressions – little or no ability to express and understand emotional

expressions (sadness, happiness).
• Use of gestures – little or no ability to express or to understand gesticulation

(hand waving etc.).
• Inappropriate body position or movements (shrugged shoulders, nodding, and

spinning).
• Communication (personal) space – not respecting it; their personal space can be
either too big or too narrow.
• Prosodic factors (melodies, rhythm of talk etc.) – the voice may be too high or
too low; monotonous, staccato (short talk), legato (prolonged talk).
• Other communication forms – using another person’s hand as a tool to get

something (putting a hand on the door means “open the door”).
• They may have very high tolerance of pain (they don’t mind their own injury)
or strange ways of expressing pain.
• They may have very low tolerance of waiting.
• They may have rage attacks (including aggression towards their surroundings
or towards themselves) while waiting for something or in situations that bring
changes in their rituals or as a reaction to a specific impulse (word, context …).
Communication/interaction strategies for people with autism spectrum disorder3
• Avoid sudden movements.
• Move slowly, performing exams from distal to proximal.
• Explain what you plan to do in advance and as you do it. Explain where you are
going and what they may see and who might be there. This may avert unneces-
sary anxiety and/or outbursts of aggression from the patient. Individuals who
appear not to understand may have better receptive language, which may not
always be entirely evident.
• Expect the unexpected. Clients with autism may ingest something or get into
something without their caregivers realizing it. Look for less obvious causality
and inspect carefully for other injuries.
• If possible ask a caregiver what the functional level of the individual with
autism is, then treat accordingly. Stickers, stuffed animals and such items which
are used to calm young children may be helpful even in older patients.
• Attempt to perform exams in a quiet spot if at all possible, depending on the

severity of injury and safety of the scene. Demonstrating what the exam will
consist of on another person first may help the person with autism have a
visual knowledge of what your intentions are.
3 Rzucidlo, S. F. (2007). Autism 101 for EMS, from SPEAK Web site: www.papremisealert.com
Evacuation of people with intellectual disabilities
• People with intellectual disabilities may need more time to mobilize support, to
arrange transport and to find a suitable target place to evacuate to.
• People with limited mobility should be supported to arrange emergency trans-

port plan in advance.
• Research shows that most emergency situations happening in nursing homes

or hospitals were well managed thanks to flexible staff and other people
(friends, families). Staff providing primary medical care may be interrupted
or busy due to the evacuation process and it may make it difficult to give the
necessary care.
• Shelters in big buildings such as schools may cause disorientation to people

with intellectual impairment and dementia. The noise, and more and quicker
activity may cause chaos. An unknown environment and a gathering of many
people may be a problem for people with autism.
• It is necessary to support persons with intellectual disabilities in adjusting to

a new environment – as a first step it is important to minimize confusion and
then re-establish structure as soon as possible.
• In case of evacuation of an institution for people with mental disabilities we

recommend cooperation with a second similar institution where clients can be
transported and looked after in similar way.
• In substitute accommodation/shelter, services must be accessible – including

communication technologies (interpreter, assistive technologies, printer, assis-
tance for people with mental disabilities etc.).
7.3.3 Emergency recovery
In the recovery phase normality and additional care should be established.
• Support in re-establishing daily activity structures; help in regaining normality/

returning to the usual functioning of services and continuity of care.
• Refer to therapy if needed/ Ensure psychological care if needed.
• Focus on stabilization techniques.

• Criteria showing that additional care is required:
– Prolonged or recurrent severe signs of distress (in spite of medical treat-

ment), sleeplessness, restlessness, no ingestion, dissociation, lacking involve-
ment in group behaviour, lack of understanding or acceptance
• Give mental health care if needed and appreciate the work of caregivers.
• Provide counselling for facilities with special needs to ensure long term recov-
ery. Coach caregivers in how to support clients.
• People with intellectual disability can and should be involved in mourning

rituals.
• The risk target group usually obtains less financial and material help after disas-
ters. That is why they need more support and guidance.
• The problems start with managing official procedures including the require-
ment to fill in forms on a computer and to apply online.
• People with intellectual disabilities often have poor orientation in a new

environment. A person with an intellectual disability often has problems in
directional orientation and numbers. If it is necessary to send this person some-
where to an office it is always better to go with him/her as a guide. Although
this person may find the right office he/she is still afraid to enter and so often
leaves with no result or keeps waiting, letting other people go in (overtake).
• Lower capacity to understand written text. We should read the text together,
explain it, and ensure they understand. We should not just give the paper to the
client to fill in.
• People with mental disabilities can be afraid of losing social or other benefits.
• Older people may be ashamed to accept help (they may perceive it as being
stigmatizing) or may feel that other people need help more.
Physical impairments 8
Ask Elklit, Louise Damsbo Simonsen, Adnan Todorovac

Physical impairments have many forms. They may entail congenital limb and torso
motor impairment, mobility disabilities after injuries, limited mobility due to age,
bedridden patients, people with different levels of self-care, and various compensa-
tory devices (dentures, crutches, walkers, wheelchairs).
Some may have a simultaneous involvement of speech and facial muscles (lay
people can sometimes confuse the symptom with drunkenness or mental retarda-
tion).
Because combined disabilities occur so frequently, we give some guidelines here

that apply to people with physical disabilities.
Physical disability does not affect the affected person’s understanding of what is
communicated, but if we want to establish trust, it is good to provide these people
with the maximum possible comfort.
Not all people with physical disabilities experience a combination of mental and
physical or sensory impairment. The type of help required differs in these people
as do their self-help and self-care capabilities.
Immobilized patients: Each movement is carried out according to the will of

another person, but the ability to perceive it is retained. These patients are physi-
cally the most vulnerable.
Long-term bedridden patients have chronic problems, sensory deprivation, whole

body pain, and bedsores, while sensitivity of sensation is preserved. Decisions are
often made “about them without them”. Do not underestimate the importance of
communication with them!
8.1 Review of research
Adnan Todorovac, Louise Damsbo Simonsen, Ask Elklit
Rahimi (1993) examined how PD individuals acted and felt during the earthquake
in Loma Prieta in 1989. The results showed that a lack of activity during the
earthquake was not due to the PD individual’s feeling vulnerable or unsafe; instead
the individuals who reported no or little fear during the earthquake were more
likely to stay passive. The PD individuals did not think of themselves as vulnerable,
and those who felt vulnerable initiated self-protective action in response to the
hazards present in their immediate surroundings. These findings might suggest
that PD individuals have a psychological advantage when adapting to a changing
environment because they already deal with changing and difficult physical and
environmental limitations in everyday life.
However in a study regarding people’s emergency preparedness, Smith & Notaro

(2009) found that PD individuals were more likely to state that they were not
prepared for an emergency than non-PD individuals. Furthermore, they found that
PD individuals including women, minorities, non-white and individuals with low
income and low educational status were at higher risk of being unprepared for an
emergency. Sever (2015) conducted research on disabled individuals living in bom-
barded areas in Israel in 2006. The results showed that the disabled individuals had
difficulties entering the evacuation shelters, and that they did not want to ask for
further help because they felt the shelters were not adequate for their functional
needs. Some of the disabled individuals who had a place to evacuate to had no way
of getting there. Furthermore, the disabled individuals who lived alone and did not
evacuate were left behind without any safety net because many of their neighbours
had been evacuated. Individuals that lived in care facilities and were dependent on
others 24/7 were left alone without treatment, assistance and sometimes without
food and water when the care personnel evacuated with their families.
In a further study, after the hurricanes Bonnie, Dennis and Floyd in the USA, Van
Willigen, Edwards, Edwards & Hessee (2002) found that households with a PD
family member were less likely to evacuate from their homes than other families.
Reasons for not evacuating were attributed to a lack of access to transportation,
shelters, services and assistance. In addition, many of the interviewees who used
wheelchairs argued that they would not evacuate without their wheelchair.
Shpigelman & Gelkopf (2017) investigated the experiences, challenges and needs
of individuals with lifelong disabilities who had been exposed to chronic politi-
cally violent events. They found that external stressors including environmental
conditions and the response to these stressors played a major role for people with
disabilities in dangerous situations. Most of the participants reported stress due
to the inaccessibility of the physical environment, including difficulty in locating
and finding a shelter within a short time and difficulties entering a shelter whose
opening was not wide enough to accommodate a wheelchair. The study concluded
that environmental barriers might limit the PD individual’s functioning and might
increase their level of distress. To sum up, these studies show that it is important to
have an effective evacuation system and evacuation plan for PD individuals when
a disaster or traumatic event occurs.
Guidelines
Practical guidelines and evacuation guides have been published in great numbers
(National Fire Protection Association, 2016; City of Los Angeles Department on
Disability, 2002; Server, 2015; American Red Cross Disaster Services, 2016), but there
is still a lack of scientifically-based guidelines. This descriptive study is the first
of its kind to be conducted in Denmark. It was part of a larger, two-year project
funded by the European Commission. The project entitled The European Net-
work for Psychosocial Crisis Management – Assisting Disabled in Case of Disaster
(EUNAD) (www.eunad-info.eu) focused on developing and implementing stand-
ardized EU human rights-related assistance programs for people with disabilities,
including PD individuals. The project represents a collaborative research effort
between partners from Germany, Czech Republic, Austria, Norway, and Denmark.
The goal of the present study was to gain insight into the experiences of PD indi-
viduals with accessing first response, healthcare and trauma-informed aftercare
services following experiences of disasters, and their suggestions for improving
these services. The rationale behind this was that their experiences with accessing
services in connection with other crisis situations could help highlight potential
areas for improvement in service provision that are also likely to be relevant in
times of disaster. Our specific research questions were as follows:
• What difficulties were encountered during crisis situations? And how did the
participants react under and after crisis situations?
Physical impairments • 135
• What experiences did the participants have when interacting with health-
care professionals (e. g. hospital staff, psychologist) and in general with the
municipality?
• What future directions should be taken to better assist PD individuals in the

event of disasters and other crisis situations?
8.2.1 No one left behind – The accessibility of medical and psychosocial services
following disasters and other traumatic events: Experiences of physically
disabled individuals in Denmark
Ask Elklit, Louise Damsbo Simonsen, Adnan Todorovac
Introduction
We are all vulnerable in times of disaster. Physically disabled (PD) individuals

are particularly vulnerable and are frequently overlooked in disaster situations
(Handicap International, 2005). PD individuals are primarily divided into three
groups: 1) wheelchair users, 2) ambulatory mobility and 3) respiratory (National
Fire Protection Association, 2016). Wheelchair users are vulnerable because of
their dependence on their wheelchair to move around. Problems when evacuat-
ing might arise if individuals in wheelchairs have to manoeuvre through narrow
spaces, move over rough or uneven surfaces or use toilet and bathing facilities in
places not suitable for PD individuals (National Fire Protection Association, 2016).
Other problems that might arise for individuals using wheelchairs are the potential
need of a pair of heavy gloves to protect their hands or a situation where a tyre
might puncture if they run over glass or debris. If it is not possible to continue the
evacuation in the wheelchair, the PD individual has to be carried (City of Los Ange-
les Department on Disability, 2002). Likewise PD individuals in wheelchairs cannot
seek shelter under tables as it is recommended in cases of earthquake nor can they
evacuate quickly out of buildings with stairs (Server, 2015). These problems mean
that wheelchair users usually are dependent on others in cases of emergency where
it is necessary to evacuate.
People with ambulatory mobility are not able to use certain limbs or coordinate
their movements. Problems might arise if they have to walk, climb steps or slopes,
stand for extended periods of times or reach and use fine finger manipulation (City
of Los Angeles Department on Disability, 2002). People with respiratory issues
may have difficulties in evacuating due to dizziness, nausea, breathing difficulties,
tightening of the throat or difficulty concentrating. These people may require rest
breaks while evacuating (ibid.).
It is difficult to say exactly how many physically disabled individuals there are in
Denmark: first of all, because there is no registration for physical disabilities in
Denmark, and second, because it is difficult to give a precise definition of the term
physically disabled. The World Health Organization (WHO) estimates that approx-
imately 10–15 percent of any given population has some sort of handicap (Danish
Handicap Association, 2017). Of the 16–64 year old in Denmark, 26% reported a
self-rated physical handicap (Centrale Handicap Advices, 2014). A study from 2002
by the Denmark State Bank showed that 744,000 individuals in Denmark between
15 and 66 years have long-lasting health problems or a handicap. This corresponds
to every 5th individual in this age group. 6% had long-lasting health problems
or a handicap in the “arms or hands category”, while the numbers were 10% for
the “legs or feet’s” category, and 28% for the “back or neck” category (Denmark’s
Statistic, 2002). More recent figures showed an increase in the last three years in
social services for individuals with mobility incapacity (Denmark’s Statistic, 2017).
According to the Danish Statistical Bank, there were approximately 4,200 individ-
uals with a physical mobility incapacity who received social security (Denmark’s
Statistic, 2017).
An important piece of legislation for PD individuals is the Convention on the

Rights of Person with Disabilities (CRPD), adopted by the General Assembly of
United Nations on 13th of December 2006 (UN General Assembly, 2007). The CRPD
provides the full range of rights for persons with disabilities, including during situ-
ations of armed conflict, humanitarian emergencies and natural disasters (Mittler,
2015). Denmark and many other European countries have signed and ratified the
CRPD. In the context of post-disaster service provision, State Parties and public
authorities have a responsibility to ensure that medical and psychosocial services
are adapted to meet the specific needs of people with disabilities, including PD
individuals.
Consequent to Denmark ratifying the CRPD, the Danish Emergency Management

Agency is obligated to provide equal opportunity and accessible services to assist
PD individuals especially in the events of disaster. Regarding the organization of
local emergency responses to disasters and accidents, guidelines laid down by the
Danish Emergency Service Act stipulate that local councils are responsible for
providing reasonable assistance for personal injuries and property damage. This
obligation also covers persons with disabilities (UN Committee on the Rights of
Persons with Disabilities (CRPD), 2017). However, to be effective, post-disaster assis-
tance should also promote the psychosocial well-being of survivors. First response,
healthcare and trauma-informed aftercare services play a crucial role here. It is
not currently known whether such services in Denmark are properly equipped to
respond to the specific needs of PD individuals following disasters. Documenting
the experiences of PD individuals of accessing these services is therefore crucial.
To our knowledge no Danish studies exist that investigate how PD individuals

experience a traumatic situation and the services after the event. Moreover, we are
aware of only a limited number of international studies on PD individuals exposed
to traumatic events [Server, 2014; Smith & Notaro, 2009; Rahimi, 1993; Shpigelman
& Gelkopf, 2017; van Willigen et al., 2002).
Methods
Participants
Disasters are relatively uncommon in Denmark, hence recruiting PD individuals

with disaster experience proved difficult. We therefore expanded our recruitment
strategy to include PD individuals who had experienced other critical situations
(e. g. accidents, personal crises). A total of twelve (n = 12) PD individuals were
selected to participate in this study (Table 1). All were of Danish nationality. The
majority (n = 9) were males. Participants’ age ranged from 23 to 54 years. Five (n = 5)
were wheelchair users and five (n = 5) were electrical wheelchair users due to either
acquired injuries in accidents, sclerosis, osteoporosis, cerebral palsy or congenital
disability. One wheelchair user also had respiratory issues. Two (n = 2) had ambu-
latory mobility. We recruited participants through several handicap organizations,
Danish Handicap Associations (DH), via a workshop at the University of Southern
Denmark, and through advertising on social media (e. g. Facebook).
Table 1: Summary of characteristics of study participants (n = 12)
Pseudonym Sex Age Reason for physical disability Wheelchair/Ambulatory

disability/Respiratory issues
Brian M 40+ Working accident Electric Wheelchair
Rasmus M 40+ Sclerosis Wheelchair
Simon M 50+ Traffic accident Electric Wheelchair
Oliver M 30+ Cerebral palsy Electric Wheelchair
Sebastian M 30+ Congenital Osteoporosis Electric Wheelchair and

Respiratory issues
Birgitte F 40+ Ehlers-Danlos syndrome Ambulatory disability
Pernille F 20+ Dysmelia Ambulatory disability
Anna F 60+ Congenital physically disabled Electric Wheelchair

Pseudonym Sex Age Reason for physical disability Wheelchair/Ambulatory

disability/Respiratory issues
Mathias M 40+ Broken spine due to accident Wheelchair
Tobias M 50+ Broken spine due to accident Wheelchair
Søren M 20+ Traffic accident Wheelchair
Carsten M 30+ Parachute accident Wheelchair
* Ages are not precise for anonymity reasons
Materials
A semi-structured interview guide was developed by the authors. The first part
identified a crisis situation (e. g. daily crisis, disaster or terrorism) and included
open-ended questions (e. g. “How did you react in the crisis situation? Thoughts?
Feelings?” and “How far did you experience the professionals as experienced in
helping people with physical disabilities?”). The second part of the interview guide
focused on the individual’s coping with the situation and possible psychological
help seeking (e. g. “Has your life changed after the crisis situation?” and “Where did
you seek support after the crisis situation? Family, friends, professionals?”). The
third and final part included questions about future recommendations for profes-
sionals (e. g. “What should professionals be aware of when rescuing people with a
physical handicap?” and “What could emotionally hurt you in an attempt to rescue
you?”). The participants were likewise encouraged to include any experiences they
might consider relevant.
Procedures
Data collection took place between October 2016 and June 2017. The authors
followed the Nordic ethical guidelines for psychologists. Prior to the interviews,
participants were informed about the study objectives as well as issues of anonym-
ity and confidentiality. They were also informed about their right to drop out of
the study at any time. All participants provided verbal consent to participate in the
study. The interviews were conducted by the two first authors. Three of the partic-
ipants were interviewed in a group. The others were interviewed on an individual
basis. Interviews lasted approximately 1–3 h. The majority of the interviews took
place in participants’ homes or other places nearby (e. g. workplace, community
center). All interviews were recorded on tape. The interviews were subsequently
transcribed by the authors. We each reviewed the transcripts several times and
identified key recurring themes associated with each category of research question.
The authors discussed the themes during face-to-face meetings. Disagreements
about themes were deliberated until consensus was reached.
Results
The main themes emerging from the analysis are presented in this section.
Category 1: Difficulties encountered during crisis situations
One major complaint almost all of the PD individuals had in common was that
there was a lack of guidelines and evacuation plans in case of emergency. None of
the participants were familiar with any general recommendations or guidelines.
Furthermore, in some cases when there was an evacuation plan, it had not con-
sidered the physical state of the PD individuals and would not be effective or easy
to carry out in case of an emergency. Another problem was that sometimes when
equipment was described as handicap-friendly it might be useable for individu-
als with mild PD but not suitable for the individuals with more severe PD. One
participant, Tobias, stated that putting a handicap-friendly sticker on something
would not make it handicap-friendly. Several PD individuals should have to try it
out before it could be called handicap-friendly.
One individual experienced when visiting his rehabilitation physiotherapist that

the evacuation plan was to get everybody up onto a flat roof from where they were
to climb down a ladder. The roof was accessible through a door raised 35 cm from
the floor, without a ramp.
> “My physiotherapist said, ‘You are not the problem. We will get you down’.
But they did not know what to do with the electrical wheelchair that weighs
100 kg by itself. They had to rethink that. They had an evacuation plan, but
it was not optimal!” (Søren, wheelchair).
The majority of the PD individuals stated that they have to plan their entire day
around their disability. Despite the planning, many of them had not thought about
their general emergency preparedness and lacked sufficient planning and thought
in case of something unplanned would happen. Many of the participants believed
that it was important to consider possible crisis-related situations, or at least have
thought about what to do if an emergency emerged. However, several reported
that they themselves were not ready in cases of an emergency.
> “Itwantis important that we think about what we are going to do and how I
people to react if I find myself in a situation of crisis. These are not
pleasant thoughts but they are important to consider, because only when
you are ready to die can you truly live.” (Pernille, ambulatory disabilities).
A few PD individuals had discussed the issue of potential crisis with their helpers
and relatives, and had stated that in cases of emergency the person had to save
himself and not risking their own life in trying to save the PD individual.
> “Then I came home, and I said to my husband. We have to talk about if
something happens in the metro or something like that. Have you consid-
ered you may have to run and abandon me? Then he looks at me and says;
We cannot do that! And I say; You might have to. What if we agree that is
what I want you to do?” (Birgitte, ambulatory mobility).
Instead of planning what to do in case of emergency, more of the PD individuals

had the belief that everything would work out fine, even if they were not prepared.
Almost all of the PD individuals who had 24 hours of help stated that they were
sure their helper could save them and therefore did not think about what to do if a
crisis situation occurred. Anna states that “having the autonomy and freedom to do
what you want is more of a priority than safety.”
Some of the PD individuals explain that it can be difficult to make general rec-
ommendations on evacuation plans for PD individuals because there are so many
different types of physical disabilities; a person with ambulatory disabilities and
a person in an electric wheelchair does not necessarily require the same type and
range of help. An extra problem arising for PD individuals who do not use a wheel-
chair is that their disability might be invisible. It might therefore be hard to gain
the help they need. Pernille emphasises that she has a prosthesis which means she
cannot run; this can be hard for others to understand in a crisis situation because
the prosthesis is not so easy to spot.
> “No two wheelchair users have the same needs, and it is therefore difficult
to put into a system […]. You have different needs, so it is important to listen
to the individual needs instead of pinning them down.” (Brian, electrical
wheelchair).
Because of the different needs, one PD individual, Mathias, suggested that if you
make an evacuation plan based on the worst case of physical disability, then you
are ready to help almost all types of physical disabilities in case of emergency. It
might even be easier to evacuate the individuals whose disability is less severe
because they might not need as much help as planned.
Many of the participants agreed that test evacuations are a good idea and can make
a real evacuation easier, but they also underlined that a test evacuation loses its
purpose if the disabled individual is left behind because it is too difficult to include
them. One individual in an electric wheelchair, Oliver, was left behind in a test
evacuation at work and would stand inside and wave to his colleagues that had
been evacuated to the ground outside. He emphasizes that in a test evacuation you
find out the best possible way out and where you need improvements. It is also
the time where you can agree upon who has to lift the person if it is not possible
to bring the wheelchair. An ambulatory mobility individual, Birgitte, often experi-
enced being left behind in test evacuation situations in school because there were a
lot of stairs that would take too long for her to walk down by herself and it was too
difficult to help her down.
Another participant in a wheelchair, Søren, experienced a fire alarm that started in

a museum. He was with another disabled man who was in an electric wheelchair.
The elevator did not work and when they got to the emergency exit there were
five steps up to the door and no ramp. Søren could drag himself up the stairs, but
his companion could not. When the staff arrived, they told him he had to leave the
man in the electric wheelchair because they could not get him up the stairs.
> “Ithattoldtheythemlearned
that it did not work. They thought this was a kind of situation
something from. Luckily for them it was a false alarm,
because if it was not a false alarm, what would they have done? The man
had his wife and children with him, but he was just to be abandoned. I told
them they had to have a ramp and they answered they would take it into
consideration. I think it should not be considered. It should just be done!”
(Søren, wheelchair).
Two of the participants had ideas could be implemented that could help PD indi-
viduals in crisis situations. One participant, Pernille, suggests that in public places
there could be a giant yellow pillar where PD individuals, in case of emergency,
could go and find help from someone who had been educated in how to help PD
individuals. Another participant, Tobias, suggested there could be an extra high
table in case of earthquake where a person in a wheelchair can drive under or a
table that can be raised or lowered.
One of the participants, Mathias, explained that the law requires that ramps have to
be 4 meters wide and that the slope has to be slow rising. Both he and other partic-
ipants thought that in an evacuation situation it does not matter that much if the
slope is a little bit steeper or the ramp a little bit narrower, as long as a wheelchair
can get up and away from the danger. A ramp gives a chance to escape whereas no
ramp can make it almost impossible for some disabled individuals to get evacu-
ated. Making buildings more handicap-friendly is not something that necessarily
cost a lot of extra money. Anna described that when the new building for The Dan-
ish Handicap Associations were built, they focused on making it handicap friendly.
This resulted in a building that it was easier for PD individuals to escape from in
case of evacuation with elevators working even in case of fire. This project ended
up costing the same as if the building had been built without the extra considera-
tion for PD individuals.
Category 2: Reactions under and after crisis situations
The PD individuals’ reactions under crisis situations ranged from freezing com-
pletely to getting very involved in sorting out the problem. Some of the individuals
had a hard time asking for help while others just wanted their lives prioritized and
help to get away and survive, and things like wheelchairs and the risk of broken
bones came second. A PD individual, Mathias, stated that the only thing that you
can do in situations of crisis, where you as an individual are dependent on your
wheelchair and cannot evacuate yourself, is to scream for help and pray that some-
one comes to your rescue.
The reactions after the crisis situations ranged as much as the reactions under the
crisis situation. Some of the individuals became more watchful while others were
not affected by the situation. None of the participants saw a psychologist directly
because of reactions arising after a crisis situation. Instead some of the participants
sought out help from other PD individuals, who had already faced similar situa-
tions, and described how it can be helpful to talk to people who can relate to your
situation. One individual, Rasmus, told that the happiest and most positive PD
individuals and those who share the most experiences were the ones who had been
physically disabled the longest.
> “Aunderstand.
psychologist can never say: I know how you feel, because they cannot
I was offered help from a psychologist right after my incident,
but I said no. I would rather talk to another physically disabled person or
other individuals in the same situation as me than with a psychologist.”
(Søren, wheelchair)
According to several PD individuals, thinking about emergency situations can be

too negative, which makes them more prone to try to think more positive thoughts
and avoiding the negative. Some of the participants described that the general PD
individual starts off by being negative when he/she first receives the news about
being disabled. Later most PD individuals become more and more positive as he/
she learns to live with the disability.
> “You can get sick of it, if you always have to think about all the negative
stuff and what might happen. It is always the family that worries more
about what might happen. It is only a problem if you make it a problem.”
(Søren, wheelchair)
However some PD individuals still deny that they have a disability or that their
disability makes them different from everybody else. They are trying to live their
lives as normally as possible without considering the disability.
> “IbutamI amjustnotlikedisabled.

everybody else. I am not disabled. I might be in a wheelchair
” (Sebastian, wheelchair)
Category 3: Interactions with healthcare services
Some of the PD individuals state that they have encountered hospital personnel
that lacked both empathy and knowledge about differences between physically
disabled individuals and individuals without physical disability. Birgitte always felt
she got too much attention because of her rare disease; when she is hospitalized a
lot of extra doctors enter her room just to watch. She does not feel the doctors are
taking her feelings into consideration. Brian have also experienced doctors that
lacked empathy.
> “The first doctor I talked to when I woke up after surgery, his first words
were, ‘Do not expect to be able to move more than you can now’. That was
harsh. It was not what you needed to hear as the first thing after waking up.
[…] After five to six days I complained about pains in the middle of the night.
A doctor comes in and the first thing he says is, ‘Sit up straight so I can listen
on your back’.” (Brian, electrical wheelchair).
Simon experienced how a lack of knowledge about PD individuals can cause more
damage than healing when getting treated in the hospital. After breaking a leg the
doctor put on a cast that resulted in a wound that worsened his condition more
than a broken bone.
> “When you cannot feel anything, you must not put on a cast. The first time
I broke my leg they treated me like everybody else. They put on a cast and
before I could convince them that I should not have a cast, and the chief
of surgery convinced them, 14 days had passed, and I had got a pressure
sore on the heel that took over a year to heal. […] You have to think different
when you are paralyzed. They did not take that into consideration; it was
very problematic.” (Simon, electrical wheelchair).
Furthermore, several PD individuals stated that their own expertise on their disa-
bility was not taken into consideration by the hospital’s social offices. Most of the
staff were trying to lecture about the disability but no one seemed to have the time
to listen to what experiences the PD individuals had themselves. One PD individ-
ual, Birgitte, stated that when she tried to offer ideas for better solutions on how to
improve things at the hospital, she was ignored because of the lack of resources.
All the individuals who had a handicap helper said they often experienced that
when encountering new people, the latter often communicated with them
through their helper. The newly encountered people assumed that a physical dis-
ability was equal being totally disabled and not being able to have a conversation.
Therefore the PD individuals had to tell them that they are fully able to communi-
cate themselves. They pinpoint the need to feel autonomy even though they need
help. Likewise, the PD individuals underlined the importance of remembering
the person behind the handicap and remembering to show empathy and not just
sympathy. They need information about evacuation plans like people with no
disabilities.
> “II have

have experienced a couple of times that when I am out shopping in places
not been before and I have my helper along, people tend to commu-
nicate to the helper and not me. My helper tries to explain that I am the
one they should talk to. Sometimes we act like we do not know each other,
thereby forcing the employers to talk to me. It is just because people do not
know better.” (Sebastian, electric wheelchair).
Category 4: Municipality problems
Several PD individuals have had different experiences in services provided by the

municipalities. It varies a lot from municipality to municipality how much help
they will grant a PD individual and how hard the individual has to fight to get the
things he is legally entitled to.
One participant recounts that first of all there are too many small laws and regu-
lations and that you as a PD individual have to know exactly what you are entitled
to; otherwise you might not get what you need. Therefore many PD individuals
state that you have to be socially skilled and know how to provide the best argu-
ments.
> “Some municipality offices are totally insane. They are trying to save
money on everything, and people are not getting the most basic stuff. I
know someone who could not get granted something they needed, so they
moved to a different municipality and got a handicap car. It is not fair that
some people get everything they need and things they don’t need, while 10
others do not get the most basic stuff for their disability. There is a lack of
guidelines.” (Mathias, wheelchair)
When the municipalities have budget cuts it can have serious impact on PD indi-
viduals. Simon experienced in his municipality that his help service was reduced
from 20 hours a day to 11 hours a week. Because of this he did not get help getting
turned around at night to avoid bed sores, which resulted in pressure ulcers and
later blood poisoning. He ended up staying at the hospital for 9 months because of
this. Afterwards when he moved to another municipality he got back his help for
20 hours a day. Another PD individual, Birgitte, feels obligated to equip herself with
several helping devices such as collars, walking sticks and knee shin pads when
going to meetings with her social worker at the municipality, even if she doesn’t
need those specific helping remedies that exact day. When Birgitte is wearing her
assistive devices, her experience is that communication is easier and that the social
workers understand that she has a handicap even though you might not see it
without the devices. Birgitte once took a test that concluded she needed help at
home, and the municipality urged her to apply for help. She has applied more than
once because she kept getting rejected because she was married and therefore had
a spouse that could help her. One time she was granted help to clean the house,
but this was retracted when they found out they made a mistake and that she was
married.
> “The municipality office says that the test concludes that you need help
in your home, and encourages to apply for help. Then you do that and
get rejected because you are married and have homebound children.
The municipality office knows this […]. If I was to file a divorce, and live
by myself and still had homebound children, then I could get all the
help I need. But I am so silly that I am married.” (Birgitte, ambulatory
disabilities).
Recommendations
This is the first study to investigate barriers faced by PD individuals in Denmark

when accessing medical and psychosocial services following disasters and indi-
vidual traumatic experiences. The use of semi-structured interviews enabled us to
gain an in depth understanding of participants’ experiences.
Regarding difficulties encountered during interactions with healthcare profession-

als, all our participants expressed concerns about the lack of guidelines for evac-
uating PD individuals in situations of crisis. This finding is consistent with those
of previous international studies investigating PD individuals’ experiences with
evacuations (Server, 2015; Shpigelman & Gelkopf, 2017; Van Willigen et al., 2002).
Test evacuations are a good way to prepare how to evacuate, but even though it
makes the evacuation longer and more difficult, it is important to include the PD
individuals as it will not be any easier to evacuate them in a real danger situation.
It should be considered that there are a lot of different handicaps, and that health-
care professionals should be aware of special individual needs. Equally, it should
be mentioned that PD individuals react differently in different situations of crisis.
Participants in electric wheelchairs specify that their wheelchair is extremely
important for them to bring along, because if they leave their wheelchair they
will be absolutely helpless, whereas this is not so important for the participants in
non-electric wheelchairs. It is important to remember that PD individuals with
different disabilities can have very different needs in cases of crisis. Therefore it
should be considered that guidelines should be suitable for PD individuals with
more severe disabilities, because this can also ease the evacuation for PD individu-
als with less severe disabilities.
Another important point is that PD individuals should prepare themselves and talk
with their family and friends about what to do if a crisis situation occurs. Some PD
individuals might take for granted that their helper will evacuate them in times of
crisis, and it is therefore important to talk about the different expectations the PD
individual and the helper might have.
Some participants felt that healthcare professionals lacked knowledge about the
difference between treating PD individuals and non-PD individuals. This lack of
knowledge can lead to more harm than good when treating PD individuals. Some
of the participants experienced that the healthcare professionals showed limited
empathy and did not listen to the recommendations the individuals presented
afterwards.
Furthermore PD individuals experienced that several times the healthcare profes-

sionals and other professions did not communicate directly with them but with
their helper. It is therefore important that healthcare professionals are instructed
in the differences between treating different PD individuals and non-PD individ-
uals and do not just leave this information for the specialized doctors. It is also
important to show empathy and maybe consider the help PD individuals offer
when they come with ideas and support in how to improve the treatment of PD
individuals.
As a PD individual living in Denmark, you have to consider which municipality to

live in, as there are big differences between municipalities in relation to how hard
it is to get help and services. Likewise, you as a PD individual have an obligation to
know the laws and what you can demand; otherwise it can be hard to get the help
you need. More general guidelines on what PD individuals have the right to could
improve living standards and quality of life for some PD individuals.
Therefore the following could be considered when making guidelines for PD

individuals:
Recommended Guidelines
• Guidelines for the municipality and the government
– Make general recommendations for PD individuals in case of

evacuation.
– Make it easier and more equal for PD individuals to get access to the
help they need.
– When planning a new building, consider making it easier for PD indi-

viduals to escape.
– Place more ramps in places where it can be difficult to evacuate a PD

individual.
– Provide information campaigns about how to offer help to PD individu-

als in evacuation situations.
• Guidelines for Healthcare professionals
– Extend the knowledge about differences in treating PD individuals and

non-PD individuals.
– Remember there is a person behind the handicap and show empathy.
• Guidelines for evacuation
– Extend the knowledge of how to evacuate PD individuals in situations

of crisis.
– When evacuating a PD individual, inform them about what is going to

happen.
– Include the PD individuals in the test evacuations.
– Bring their wheelchair if possible.
– Remember not all disabilities are visible.
– Make space on the road and to evacuation buildings so people who are
in a wheelchair or are inhibited can make their way through.
• Guidelines for the PD individuals
– Be informed about the evacuations possibilities.

– Prepare an emergency preparedness kit (e. g. gloves, support bandages,

etc.).
– Talk to friends and family about what to do in a crisis situation.
• Guidelines for caregivers and families
– Provide emergency preparedness training.
– Respect the autonomy of the PD individual.
The limitations of the present study are acknowledged. The reliance of this study
on convenience sampling and its small sample size restrict the generalizability
of the findings. In addition, our study sample consisted of PD individuals who all
functioned well mentally in their daily life. All the PD individuals were of ethni-
cal Danish nationality and had an average-to-above socioeconomic status. It is
possible that the experiences reported by our participants present a more positive
depiction of healthcare service provision following disasters and other traumatic
events than those of the target population at large. Because it is not a common
thing in Denmark to experience disasters the current article presents a picture of
less severe traumatic experiences and might not show the same results as if it was
conducted with more severe traumatic experiences.
While some of our recommendations may also apply to the provision of services
for other PD sub-populations, future research is still needed to yield additional
recommendations. Furthermore, since the scope of this study was limited to inves-
tigating the perspectives of PD individuals on the accessibility of services typically
responsible for responding to disasters, future research should inquire into their
perspectives on emergency preparedness initiatives implemented in Denmark
as well as in other countries. Our recommendations are consistent with some of
the Key Recommendations for Supporting Persons with Disabilities in Disasters
from Austria (Juen et al., 2016) and the Emergency Evacuation Planning Guide for
People with Disabilities from America (National Fire Protection Association, 2016).
Because it is uncommon for disasters to happen in Denmark, some of the recom-
mendations from other countries seem unnecessary, but it is still important to
consider if they should be implemented in Denmark as well.
References
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Centrale Handicap Advices. (2014): Mennesker med handicap i Danmark (2017).

http://www.dch.dk/sites/default/files/Mennesker%20med%20handicap%20i%20
Danmark_FINAL.pdf [Accessed 21 January, 2017]
City of Los Angeles Department on Disability. (2002): Emergency Preparedness For

People with Disabilities. LA
Danish Handicap Association. (2017): Den svære balancegang. (eng. The tough
balance). https://danskhandicapforbund.dk/da/presse/presserum/fakta-om-handi-
cap/tal-pa-handicap-i-danmark/ [Accessed 27 March, 2017]
Denmark’s Statistic. (2002): Helbredsproblemer og arbejdsliv. (eng. Health issues

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?id=6538&sid=helb [Accessed 27 March, 2017]
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Services for Handicap and Physical disability). www.statistikbanken.dk/10379
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ment. Bangladesh: Dacca
Juen, B., Warger, R., Liedel, P. L., Gütler, S., Kreh, A. & Lindenthal, M. (2016): Iden-
tification and mapping of MHPSS Guidelines: A synthesis research report on key
points resulting from the inventory. European Network for Psychosocial Crisis
Management – Assisting Disabled in Case of Disaster – Implementation ECHO/
SUB/2015/718665/PREP17
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menting a paradigm shift. Journal of Policy and Practice in Intellectual Disabilities,
12(2), 79–89
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for People with Disabilities. Quincy, MA
Rahimi, M. (1993): An examination of Behavior and Hazards Faced by Physically

Disabled People During the Loma Prieta Earthquake. Natural Hazards, 7, 59–82
Server, R. (2015): Extra Fragile in Disaster. People with Disabilities in a Bombarded

Zone. In: Disaster Management Enabling Resilience, 201–226. Berlin: Springer
Shpigelman, C. N., & Gelkopf, M. (2017): The experiences and needs of individuals
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39(1), 23–35
Smith, D. L. & Notaro, S. J. (2009): Personal emergency preparedness for people with
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resolution/adopted by the general assembly, 24 January 2007, A/RES/61/106. http://
www.refworld.org/docid/45f973632.html. [Accessed 21 January, 2017]
UN Committee on the Rights of Persons with Disabilities (CRPD). (2017): Consider-

ation of reports submitted by State parties under article 35 of the Convention, Initial
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Natural Hazards Review, 3(3), 98–106
8.3 Recommendations for physically impaired people
The following recommendations are based on multiple sources, one being the
literature analysis of the topic, mainly using the guidelines based on research or
particular experiences. Another source was a workshop with emergency rescue
services representatives, therapists and other specialists working with the target
group and a physically impaired participant. They shared their experiences and
expertize and gave feedback to the information from the literature sources. A third
source was a qualitative study carried out within the frame of the EUNAD projects.
The University of Southern Denmark and the Charles University in Prague are the
implementing institution.
8.3.1 Emergency Preparedness
• Make general recommendations for PD individuals in case of evacuation.
• Implement ways to make it easier for first responders to access important infor-
mation concerning the disability, e. g. QR codes connected to the individual or
individual medicine cards (used in some countries).
• When planning a new building, consider making it easier for PD individuals to

escape.
• Extend the knowledge of how to evacuate PD individuals in crisis situations.
• Implement emergency preparedness training.
• Extend the knowledge of differences in treating PD individuals and non-PD

individuals.
• Information campaigns should provide information to professionals and

the general population on how to offer help to PD individuals in evacuation
situations.
• Make work places in the public sector responsible for disabled employees and,
as far as possible, make individual evacuation plans.
• Include PD individuals in test evacuations.
• Implement first aid and fire rehearsal evacuations in elementary school that
include how to handle the most common disabilities.
• Ensure education for elementary school children regarding disabilities.
8.3.2 Emergency Response
• Be informed about evacuation possibilities.
• Remember there is a person behind the handicap and show empathy.
• When evacuating a PD individual, inform them about what is going to happen.
• Bring the wheelchair, if possible.

• Remember that not all disabilities are visible.
• A physically disabled individual may appear to be mentally disabled, even when

this is not the case. Verify the state of disability and always treat with dignity.
• Beware of increased risk of bone breakage or muscle weakness – inappropriate

handling causes risk of injury.
• Involve disabled individuals more in treatments, rights and plans.
• Remember that some individuals cannot support their own body or hold it
upright.
• Ask about specific needs and how to help with the transportation.
• Respect the autonomy of the PD individual.
• Show respect and do not override the individual’s own competence.
• Respect an alternative reaction. Individuals with disabilities have often learned

to live with their physical limitations and might react unexpectedly.
• Provide information that is timely, reasonable, and true and contact or commu-
nicate with relevant caregivers if needed.
• Assign specific individuals to communicate with the patients and be aware of

special needs.
• Prepare an emergency preparedness kit (e. g. gloves, support bandages, etc.).
• Encourage the physically disabled to talk to friends and family about what to do
in a crisis.
8.3.3 Recovery (Psychosocial)
• Make psychological counselling for individuals with disabilities and their rela-
tives more easily accessible.
8.3.3.1 Implications for rehabilitation
• Medical and psychosocial services should be properly prepared to assist PD

individuals.
• The Danish study highlighted difficulties faced by PD individuals when access-

ing healthcare and psychosocial services. These centred on a lack of guidelines
and lack of fully optimal professional services in both healthcare and the
municipality offices. Guidelines should be produced for healthcare and psy-
chosocial services, and professional services; in both healthcare and the local
authorities should initiate collaboration to fully optimize their operation for
the PD population.
• Regarding rehabilitation after disasters, evidence-based information about how

to service the needs of PD populations should be disseminated to professionals,
and preferably incorporated into training programs and evacuation plans.
8.3.4 Guidelines for communication and interaction with people with physical
disabilities
We apply the same basic principles as with people with cognitive and perception
difficulties:
• We treat the person like any other person.
• It often helps to ask the individual how to help with transport and what his
specific needs are.
• To stabilize people it helps to provide information (timely, reasonable and true)

and contact and communication with close persons. We arrange contact with a
close person.
• When communicating with a person with physical disability, we always main-

tain his human dignity and respect.
• We offer help, ask what we can do and what the individual can do him/herself.
• We strive for the individual’s own activity, we do not override his own
competence.
• We adapt to his/her abilities.

• We do express sympathy for the person, we respect differences in movement.

People with disabilities have often learned to live with their disabilities.
8.3.5 Specific recommendations
• Beware of increased bone breakage or muscle weakness - inappropriate han-

dling brings a risk of injury.
• For wheelchairs, follow the wheelchair user’s recommendations.
• Wheelchair handling – fold and unfold a wheelchair: apply brakes, remove

cushion (if any), adjust the footrest, rotate them out or remove them, hold the
midpoint of the seat at the front and back, pull upwards and fold the wheel-
chair. To unfold push the seat. Beware of finger injuries when handling.
• Transport of wheelchair down stairs: 1. Take the wheelchair forwards down the
steps; 2. Grip the handles firmly and tilt the wheelchair, balancing on the rear
wheels; 3. Move the wheelchair to the top of the first step; 4. Use your body as
brake while gently lowering the wheelchair; 5. Control the descent with your
body, keeping the rear wheels tight against the stair edge and rolling the wheel-
chair forward and down the step; 6. Don’t let the chair drop unevenly or too
quickly. A second person helps at the front of the wheelchair. A light person can
be carried downstairs in the wheelchair.
• Getting up the stairs likewise (pull the wheelchair with its back to the stairs).
• On uneven, stony or sandy terrain we push a wheelchair with a person back-

wards. (When pushing forward, the wheels crash).
• If we want to lift a person out of the wheelchair, we should to ask how we can
grasp him or her.
• Before setting a person on the wheelchair, we apply brakes and remove the
armrest.
• Electric wheelchairs are heavy (100kg or more), so it is better to transport them

without the wheelchair user. The motors can be disconnected and the wheel-
chair can be pushed mechanically.
• When moving from an electric to a mechanical wheelchair next to it, the arm-
rests can be removed.
• The necessary width of the toilet door should be ensured as well as the height
of the washbasin.
Key recommendations for 9
assisting persons with
disabilities in case of disaster
Barbara Juen, Alexander Kreh, Michael Lindenthal

9.1 Policy recommendations
• Political commitment. Governments must make clear decisions and include

in their political agenda the commitment to make a serious effort to develop
effective disaster risk management for people with disabilities. As part of the
more general endeavour to ensure the safety of their constituent populations,
they must consistently pay attention to such people’s needs.
• Coordination and continuity. In order to guarantee the effective development,

application and monitoring of emergency systems for people with disabilities,
one particular body of governmental administration must be responsible for
co-ordination and the continuity of initiatives. It will be the task of the coor-
dinating body in close cooperation with all relevant stakeholders to make sure
that all relevant information is collected and centralised.
• Networking. If risks are to be identified and solutions found, at least one net-
work should exist that allows stakeholders to meet and exchange information
about the challenges to be met. These networks should always be open to new
members and should take full account of evolutionary changes in technology,
habits and expectations.
Key recommendations for assisting persons with disabilities in case of disaster • 161
• Strategic planning. A master plan should be set up and constantly updated. The
organisation of training activities and the evaluation of emergency exercises
should be part of a constant process of adaptation of the master plan.
• Knowledge management. A coherent program of knowledge management

should be used to ensure the transfer of acquired know-how to those who can
benefit from it. This knowledge would facilitate the organisation of training
activities and allow emergency schemes constantly to be improved. Specific
added value should be provided by the involvement of people with disabilities
and their organisations.
• Identification and optimisation of resources. The evaluation of a master plan

and constant updating of its capacities, and the general level of knowledge,
should allow stakeholders to estimate needs regarding financial, organisational
and human resources. At the same time, the best possible use of existing or new
resources may allow the action plan to be improved.
• Communication. In order to ensure that everyone is kept informed about the

state of preparedness, a good communication policy is needed. Energetic dis-
semination of information will ensure that more and more relevant stakehold-
ers are contacted and involved in the preparedness process.
9.2 Key recommendations for disaster management
• Disability should become a core, cross-cutting theme in disaster and emergency

management.
• Disability must be systematically taken up across all aspects of the disaster

management cycle4.
• All types of disabilities must be considered.
• Both helpers and people with disabilities must be prepared.
• Disaster and emergency information, services and facilities must be fully acces-
sible for people with disabilities in pre, acute and post disaster situations.
4 “The main thought behind the disaster management cycle is one of awareness. Disasters are also
seen as something one can prepare for, ideally prevent or at least diminish in its effects and not
only something one has to respond to, once the disaster happened (see e. g. Challen et al., 2012;
Elliot and Smith, 2004)” (Juen et al., 2015, p.28–29).
References
Bezev.de, Caritas International/Germany & Interessenvertretung Selbstbestimmt

Leben in Deutschland. Weigt, G. (n. d.): Including Persons with Disabilities in Disaster
Risk Reduction. Positions Paper. https://sustainabledevelopment.un.org/getWSDoc.
php?id=2343
Center for Independence of the Disabled in New York. (2004): Lessons Learned from
the World Trade Center Disaster: Emergency Preparedness for People with Disabilities
in New York. http://www2.ku.edu/~rrtcpbs/resources/pdf/lessons_learned_from_
the_world_trade_center_disaster.pdf
European and Mediterranean Major Hazards Agreement. (Europa) (2013): Guidelines

for Assisting People with Disabilities during Emergencies, Crises and Disasters. David
Alexander and Silvio Sagramola, Strasbourg, 17 January 2014, AP/CAT (2013).
www.coe.int/europarisks
Handicap International Nepal. Ulmasova, I., Silcock, N. & Schranz, B. (2009):

Mainstreaming Disability into Disaster Risk Reduction: A Training Manual.
http://www.preventionweb.net/files/24772_18591hitrainingmanualenglish1.pdf
9.3 Key recommendations for emergency/disaster managers,
planners and responders
• Identification of people with disabilities:
– Identify people with disabilities who live in the community.
– Develop a special needs registry.
• Planning with the disability community:
– Develop disability-inclusive disaster/emergency plans.
– Include local disability groups & service providers in the planning process
(also include mental disability groups).
• Disaster preparation, education and training of people with disabilities:
– Publish information and tools for people with disabilities to improve their
awareness and preparedness.
– Information events and training can help to improve the awareness and
preparedness of people with impairments.
• Training of disaster/emergency workers:
– Improve their awareness, knowledge and skills, enabling them to better

address needs of people with disabilities in disaster/emergency.
• Notification and communication:
– Provide different ways to inform people with disabilities in case of disaster.
– Television stations must be responsible for providing information for people

with hearing, visual or cognitive impairments:
· Provide important information both visually and acoustically,

· Include a sign language interpreter/open-captioning,
· Frequently repeat the most essential emergency information in a simple

message format so those with cognitive disabilities can follow.
– Emergency hotlines during an event should include TTY (teletypewriter)

numbers.
– Provide information in alternate formats (e. g. Braille, cassette, large font,

etc.).
• Provide psychosocial support:
– General psychosocial support recommendations:
· Ensure safety,
· Provide a calming environment,
· Enhance self and community efficacy,
· Enhance connectedness,
· Support in maintaining hope.
• Evacuation:
– People with disabilities may require special assistance to escape from a

disaster.
– To include people with mental disabilities, instructions need to be clear,

repetitive and straightforward.
– Use emergency transport fleets with wheelchair lifts or ramps.
– Include barrier-free non-emergency vehicles in disaster plans.
• Sheltering:
– Interior and exterior routes, entrances and toilet rooms must to be accessi-
ble for people with disabilities.
– Allow service pets in the shelter.
– Provide adequate medical care and special equipment.
– Train staff in the basic procedures for providing accessible communication

(exchanging notes, read printed information, etc.).
– Establish Special Needs shelters.
• Recovery:
– During the recovery phase, the priority must be to restore or address those
services and needs most critical to people with disabilities.
– Provide barrier-free psychological care.
– Disaster and emergency management must take into account the need
for rehabilitation and follow-up services for persons with disabilities and
injured people.
References
American Medical Response Office of Emergency Management. (2003): Guidelines

for Evacuation of Individuals with Disabilities During Disasters. https://www.amr.
net/solutions/federal-disaster-response-team/references-and-resources/guide-
lines-for-evacuation-of-individuals-with-disa.pdf

Leben in Deutschland. Weigt, G. (n. d.): Including Persons with Disabilities in Disaster
Risk Reduction. Positions Paper. https://sustainabledevelopment.un.org/getWSDoc.
php?id=2343
Blanck, P. D. (1995): Disaster mitigation for persons with disabilities.

http://www.accessiblesociety.org/topics/independentliving/disasterprep.htm
Center for Independence of the Disabled in New York. (2004): Lessons Learned from
in New York. http://www2.ku.edu/~rrtcpbs/resources/pdf/lessons_learned_from_
the_world_trade_center_disaster.pdf
Connecticut Council on Developmental Disabilities. Pappanikou, A. J. (2006):

A Guide for Including People with Disabilities in Disaster Preparedness Planning.
http://www.ct.gov/ctcdd/lib/ctcdd/guide_final.pdf
Hobfoll, S. E., Watson, P., Bell, C. C., Bryant, R. A., Brymer, M. J., Friedman, M. J.,
Friedman, M., Gersons, P. R., De Jong, J. T. V. M., Layne, C. M., Maguen, S., Neria, Y.,
Norwood, A. E., Pynoos, R. S., Reissman, D., Ruzek, J. I., Shalev, A. Y., Solomon, Z.,
Steinberg, A. M. & Ursano, R. J. (2007): Five Essential Elements of Immediate and
Mid-Term Mass Trauma Intervention: Empirical Evidence. Psychiatry 70 (4), 283–315.
www.ncbi.nlm.nih.gov/pubmed/18181708
National Organization on Disability. (2005): Guide on the special needs of people with
disabilities for emergency managers, planers & responders. http://www.disastersrus.
org/MyDisasters/disability/epiguide2005.pdf
U. S. Department of Justice. (2006): An ADA guide for local governments. Making

Community Emergency Preparedness and Response Programs Accessible to People
with Disabilities. http://www.ada.gov/emerprepguidescrn.pdf
9.4 Key recommendations for people with disabilities
• Be informed:
– Learn about the types of hazards that may impact your community and
about specific types of emergencies.
– Inform yourself about specific services and programs for people with disa-
bilities in disaster or emergency and contact your local emergency manage-
ment agency.
– If possible: register yourself at your local emergency management agency.

Some agencies maintain registers of people with disabilities so you can be
located and assisted quickly in a disaster.
• Create a Support Network:
– The network should include people you know and trust and who can check
on you within minutes to see if you need help. At home, work, school, or
in the community, your support team should help you identify and secure
resources and assess your needs before, during, and after a disaster.
• Prepare Emergency/Disaster Preparedness Kits:
– Basic Emergency Supplies Kit,
– Disability Related Supplies and Other Equipment,
– Portable “Ready Kit”,
– Make an emergency information list (Contact information of the people in

your support network).
– Make a medical information list (Information about your special medical

needs).
• Create a communication plan:
– Make sure you and your support network have each other’s contact infor-
mation and alternate ways to communicate if phones are not working (such
as an assigned meeting place, using pagers, email or other technology not
reliant on phone lines).
• Make an evacuation plan for home, work, school, etc.:
– Identify a primary and secondary way to evacuate the house or building.
– Identify transportation resources.
– Include service providers in the planning process.
– (Make a plan for your service pet).
• Consider different shelter options:
– Shelter-in-place,
– Public shelter/Special needs shelter,
p consider how these shelters meet your needs.
References
National Fire Protection Association (NFPA). Fraser, A. B. (2007): Emergency Evacua-
tion Planning Guide for People with Disabilities. https://www.nfpa.org/~/media/Files/
Safety%20information/For%20consumers/Disabilities/evacuationguidePDF.pdf
National Organization on disAbilities. (2006): Prepare Yourself. Disaster Readiness

Tips for People with Developmental or Cognitive Disabilities. http://www.disasters-
rus.org/MyDisasters/disability/epips3cognitive.pdf
U. S. Department of Homeland Security. (2007): Preparing makes sense for people

with disabilities and special needs. Get ready now. www.fema.gov/media-library-da-
ta/1440775166124-c0fadbb53eb55116746e811f258efb10/FEMA-ReadySpNeeds_
web_v3.pdf
9.5 Key recommendations for caregivers/family members/
helpers of people with disabilities
• Respect the independence of the person with disabilities
– Discuss with the person with impairments how you can help. Even though
it may be important to evacuate quickly, respect their independence to the
extent possible. Don’t make assumptions about the person’s disabilities.
• Work together with the person with disabilities to prepare for various disas-
ter and emergency events:
– Prepare a disaster/emergency plan.
– Prepare a disaster/emergency kit.
• Service provider preparedness:
– Nursing homes, hospitals and other providers of long-term services must

make response plans for the safety of their service recipients and staff dur-
ing an emergency or disaster. Those plans must include well-tested trans-
portation procedures in the case of evacuation.
• Training:
– Take part in emergency preparedness training for caregivers.
– Conduct emergency/disaster exercises and training for people with

disabilities.
• Recovery
– Hold a briefing of the activities that took place during the disaster/
emergency.
• Children with disabilities
– Explain the dangers of various disaster or emergency events for a child and
discuss how to prepare.
– Teach children how and when to call your local Emergency Medical Services
number for emergency help.
– Schools should include the needs of students with disabilities in their disas-
ter/emergency plans.
References
American Academy of Pediatrics & Committee on Pediatric Emergency Medicine.

(1999): Emergency preparedness for children with special health care needs.
http://pediatrics.aappublications.org/cgi/content/full/104/4/e53
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disabilities: a survey of Australian schools. Australian Journal of Emergency Manage-
ment, 29(1), 45–49. http://researchonline.jcu.edu.au/33280/1/33280%20Boon%20
et%20al%202014.pdf
CareServe. (n. d.): Caregiver Training.

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https://www.caregiver.org/emergency-preparedness-checklist-caregivers
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org/caregiving-ministries/ministry-home/disaster-preparation-for-caregivers-ar-
ticle.aspx
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nity Living. Keeping Older Americans and People with Disabilities Safe and Healthy
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pdf
Guideline development and 10
implementation: importance of
international cooperation and
local tailoring
Michel Dückers
Importance of international cooperation
In recent decades, different international guidelines have been developed to pro-

mote the quality of psychosocial support to people confronted with disasters and
major events like flooding, terror attacks, industrial incidents and environmental
threats. The EUNAD-IP project is part of a longer tradition in Europe to com-
bine and synthesize information from research, experts and practice in different
countries and language areas, and to translate them into practical guidance and
supportive tools. Earlier projects like TENTS, EUTOPA and OPSIC focused on gen-
eral principles and guidance for PSS, regardless of event types or particular target
groups. EUTOPA-IP and EU CBRN are examples of projects with particular accents,
respectively uniformed services and chemical, biological, radiological and nuclear
incidents. EUNAD and EUNAD-IP, were aimed at potentially affected individuals
with disabilities. During EUNAD-IP information was obtained from people with
various disabilities and collected by reviewing available literature. This information
was used to formulate recommendations that were discussed with representatives
of people with disabilities, policy-makers, and international experts. The products
created in cooperation with partners across Europe belong to the main project
deliverables and are publicly accessible. Recent analyses, conducted in the context
of the TENTS and EUTOPA projects, highlighted variation in the degree to which
recommendations were implemented in different European regions (Witteveen,
Bisson, Ajdukovic, Arnberg, Bergh Johannesson, Bolding, et al. 2012; Dückers, Wit-
teveen, Bisson & Olff, 2017) and identified a gap between guidelines and practice
(Te Brake & Dückers 2013). The projects already mentioned can be seen as a first
step in the implementation of PSS recommendations. EUNAD-IP strengthened
and expanded the existing shared European knowledge base on PSS for people
with disabilities in the wake of a disaster or major incident.
Importance of local tailoring
The next step is that the contents of the European knowledge base find its way into
local initiatives to develop and implement standards in the context of different
member states and the communities within them. After all, defining standards,
norms and other types of guidance is a necessary starting point, yet every general
Guideline development and implementation • 175
standard needs to be translated to the unique local context where it will be used.
To overcome cultural discrepancies and idiosyncrasies, and the risk of knowledge
products being welcomed as “not invented here”, it is indispensable to involve
local stakeholders and interest groups, especially the user groups, in the knowl-
edge-translation. Furthermore, within communities specific target groups and
contexts can be identified within the sub groups of people with disabilities that
require further tailoring in terms of guidance and support (e.g., ethnic groups or
children). Finally, many factors play a role in the implementation of guidelines,
interventions and tools (e.g. Greenhalgh et al., 2004; Vos et al., 2010; Michie et al.,
2011; Eccles et al., 2012; Flottorp et al., 2013). Such factors can partly be anticipated
in European projects such as EUNAD-IP. Nevertheless, in the end many stake-
holders at different levels share a responsibility in closing the gap. Future projects
can contribute to a better understanding of different local contexts and available
conditions, together with their implications for implementing PSS guidelines and
tools.
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Disaster Preparedness and Emergency Response Survey From Persons With Mobil-
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11.5 Acknowledgement
We would like to thank all participants of both the national and European work-
shops and pilot trainings for their involved discussions, their expert advice, as well
as their continuous contributions to the evaluation of the EUNAD and EUNAD IP
results.
Full account to following organizations, participants and speakers of workshops and

trainings of EUNAD:
Local workshop in Norway (NO): Center of Psychotraumatology/Alexianer/University

of Cologne (Robert Bering); Fire and rescue (June Persdatter Martinsen); Fire and Rescue
Services, Oslo (Lars Grimsgaard); Gjøvik College (Johnny Nersveen); Statped (Harald Garder
Beil, Hilde Holtsmark, Torill Lorentsen, Liv Strand); Psychologist, private practice (Åsa
Frostad Fasting); The advisory board for hearing impaired individuals (Anne Mette Dahl,
Trude Lillegjerde, Frøydis Mørk); The Norwegian Association for Blind and Visual impaired
individuals (Kari-Anne Flaa, Sverre Fuglerud); The Norwegian Association for Deaf indi-
viduals (Sissel Gjøen); The Norwegian Association for hard of hearing individuals (Steinar
Birkeland); The Norwegian center for hearing and mental health, Oslo University Hospital
(Marianne Eliassen, Randa Nilsen, Beate Øhre, Lene Hanne Urnes, Britta Barman Wold);
The Norwegian centre of violence and traumatic stress studies (Trond Heir, Marianne B
Hansen, Randi Saur); The Regional Center for Hearing and Mental Health (Mette P Uthus)
Local workshop in Denmark (DK): Capital Region Psychiatry/Psychiatric Center Ballerup,

Deaf Team (Annebrit Hjort, Per Jensen, Jeannette From Taubert); Center for Deaf, Odense
(Signe Stein Rasmussen); Center for Psychotraumatology, University of Southern Den-
mark (Anders Elbæk Christoffersen, Ask Elklit, Tina Jeppesen, Lotte Skøt); Course instruc-
tor/team coordinator Rescue Center Denmark (Eigil G. R. Hvid); Danish Deaf Association
(Lars Knudsen); Family- and psychotherapist, Private clinic (Pia Nielsen); Head nurse (Jean-
nette From Taubert); Hearing impairment Center for Disability, Technical Support and
Social Psychiatry, Social Services (Hanne Langeland); Police school, National Police (Steen
Herlev Larsen, Lotte Krag); Psychologist unit, FALCK Healthcare (Mikkel Andersen, Helle
Berentzen, Martin Zimling); Sign Language interpreter (Susanne Ørum, Jørgen Sandholt)
Local workshop in Germany (DE): ASB KV Coburg-Land e. V. Krisenintervention (Heinz

Rembor); Bavarian association of blinds and visually impaired (Svenja Seibold); Centre for
Sources • 211
psychotraumatology, Krefeld (Prof. Dr. Robert Bering, Florentine Gerwinn, Sabine Krüger,

Simone Ludwig, Dr. Dieter Wagner); City administration Düsseldorf, Emergency Psychol-
ogy (Dr. Thomas Poschkamp); Clinic Europakanal Erlangen, psychiatric department deaf
and hard of hearing (Dr. Inge Richter, Thomas Stritzke); Federal Office of Civil Protection
and Disaster Assistance, BBK (Claudia Schedlich, Gisela Zurek); German Association for
blind and visually impaired (Klaus Hahn); German Deaf Association (Wolfgang Bach-
mann); Integrationsfachdienst Köln (Sonja Denker, Jennifer Söhn); Johanniter Emer-
gency Care (Leander Strate); LWL Klinik Lengerich, treatment centre deaf and hard of
hearing (Prof. Dr. Hans-Jürgen von Giesen, Dr. Ulrike Gotthardt); SbE (Birgit Sudek); Sign
Language interpreter (Bastienne Blatz, Sandra Wolfien); Skarabee (Rafael Grombelka);
Südbayerische Wohn-& Werkstätten für Blinde u. Sehbehinderte (Dr. Birga Gatzweiler);
University Cologne, department pedagogic and didactics for deaf and hard of hearing
(Prof. Dr. Thomas Kaul)
Local workshop in Czech Republic (CZ): APPN o.s., 365 o.p.s (Mgr. Marie Horáková, Pavlína
Spilková); Association of Organisations of Deaf and Hard Hearing and their Friends,
Klub nedoslýchavých Help (Mgr. Věra Strnadová); Charles University (PhDr. Hedvika
Boukalová, Karolína Citavá, PhD., PhDr. Zbyněk Galvas, PhDr. Simona Horáková Hoskov-
cová, PhD., Karolina Klasová, PhDr. Štěpán Vymětal, PhD.); City of Olomouc (Ing. Hana
Hegerová, Ing. Jan Langr); Club of Loss Hearing people (Anica Dvořáková); Czech Blind
United (Ing. František Brašna, Mgr. Viktor Dudr, Marie Kebrdlová, Ondřej Veselý); Czech
Police (kpt. Mgr. Patricie Hausknecht, mjr. Mgr. Jana Jungwirtová); Czech Union of the
Deaf (Ing. Martin Novák, Mgr. Ota Panský); Deaf and Hard Hearing United (Pavel Šturm);
DG Fire and Rescue (plk. PhDr. Zuzana Vrbová); Federation of Parents and Friends of
Hearing Impaired (Mgr. Adéla Dědečková, Mgr. Věra Doušová, Mgr. Jana Fenclová); Fire
and Rescue (npor. nstržm. Jaroslav Gondko, Ing. Hynek Milota, kpt. Mgr. Soňa Pančochová);
National Council of Health Impaired People (Mgr. Jitka Vrchotová); Okamžik (Ing. Miroslav
Michálek, Ing. Šárka Vojtíšková); Police Presidium (plk. Mgr. Vladimír Voska); Sign lan-
guage interpreter (Monika Boháčková); Transcription (Nikola Gronesová, Tomáš Portych);
TyfloCentrum Praha o.p.s. (Ing. Jiřina Polášková, Jan Příborský); Tyfloservis o.p.s. (Olga
Buriánková, PhDr. Josef Cerha, Mgr. Petra Helebrantová)
Pilot trainings in Prague (CZ): (1) Charles University (PhDr. Hedvika Boukalová, Mgr. Petra
Helebrantová, PhD., PhDr. Simona Horáková Hoskovcová, PhD., Jakub Kamberský, Alžběta
Knorková, Martina Šašková, Karel Straka, PhDr. Štěpán Vymětal, PhD.); Czech Army (Jana
Černá, Mgr. Silvie Fryčová, kpt. Patricie Hausknecht, kpt. Mgr. Jana Jalovegová, kpt. Mgr. Jana
Jungwirtová, Mgr. Michaela Löserová, kpt. Mgr. Renata Šanderová, Mgr. František Sokol,
kpt. Mgr. Lenka Štréblová, Mgr. Drahomíra Švancarová, por. PhDr. Lenka Svítková,
kpt. Mgr. Gabriela Tabachová, kpt. PhDr. Lenka Vlášková, , Mgr. Michal Zelenka); Czech
Police (Mgr. Jiří František Průža); DG Fire and Rescue (plk. PhDr. Zuzana Dittrichová);
Ministry of Interior (Mgr. Lucie Fenclová, PhDr. Irena Gruberová, Miroslava Mocová); Police
Presidium (nstržm. Jaroslav Gondko, kpt. Bc. Jiří Janhuba, pprap. Lukáš Kaiser, nprap. Ivan
Martin, kpt. Mgr. Soňa Pančochová, nprap. Martin Sladký, por. Bc. Šmahlík Stanislav, nstržm.
Karel Teska, plk. Mgr. Vladimír Voska); Tamtam, o.p.s. (Věra Doušová) (2) Charles Univer-
sity (PhDr. Hedvika Boukalová, PhD., Mgr. Petra Helebrantová, PhDr.Simona Horáková
Hoskovcová, PhD., PhD., Jakub Kamberský, PhDr. Štěpán Vymětal); Tamtam, o.p.s. (Věra
Doušová); DG Fire and Rescue (plk. PhDr. Zuzana Dittrichová); Fire and Rescue (Mgr. Tomáš
Adámek, nstržm. Bedřich Bačovský, npor. Mgr. Lukáš Balaštík, kpt. Ing. Jaroslav Bárta, kpt.
PhDr. Dagmar Bortlík Fišerová, por. Bc. Marie Brabcová, kpt. PhDr. Michal Černík, ppor. Aleš
Chromý, nstržm. Miroslav Dobrovodský, nprap. Mgr. Novotný František, Ph.D., npor. Martin
Gaier, ppor. Mgr. David Hrbáček, kpt. Mgr. Pavel Hurta, nprap. Petr Janda, plk. Mgr. Štěpán
Kavan, mjr. Mgr. Marcela Kopaňáková, Bc. Tomáš Kubeš, nprap. Jan Kyselý, pprap. Jan
Letko, nstržm. Jiří Líbal, nprap. Karla Machalová, nstržm. Mgr. Lukáš Malík, por. Bc. Monika
Malinová, kpt. Mgr. Jana Majzlíková, nstržm. Petr Matějka, pprap. Tomáš Müller, nprap. Jiří
Necid, nstržm. Michal Nespěšný, Ph. D., por. Bc. Tomáš Nocar, kpt. Mgr. Soňa Pančochová,
nprap. Martin Prchal, nprap. Bohdan Skála, nprap., npor. Pavel Skoupil DiS., nstržm. Miroslav
Slezák, Jaroslav Smutný, pprap. Stanislav Smutný, mjr. Mgr. Hynek Sojka, npor. Mgr. Přemysl
Švajda, ppor. František Eli Svoboda, nstržm. Bc. Milan Tesař, por. Bc. Jana Váchová, mjr.
Mgr. Kvapilová Vladimíra, mjr. Bc. Zdeněk Vlasák, nprap. Jiří Vlček, pprap. Aleš Vomastek,
DiS., pprap. David Vorlíček)
Pilot training in Ahrweiler (DE): Alexianer Krefeld GmbH (Florentine Gerwinn); Arbeiter-
Samariter-Bund Kreisverband Coburg Land e. V. (Heinz Rembor); Deutsches Rotes Kreuz
Kreisverband Dortmund e. V. (Volker Kraja); Europarat/Council of Europe (Dr. Mechthilde
Fuhrer); Gesundheitsamt Landeshauptstadt Düsseldorf (Christine Druyen, Sabine Rau);
Landesschulamt und Lehrkräfteakademie (Marion Müller-Staske); Malteser Hilfsdienst
e. V. (Harald Trampert); Notfallseelsorge im Landkreis Ludwigsburg (Ulrich Gratz); Stadt
Dormagen Feuerwehr und Rettungsdienst (Jürgen Hildebrandt); Stadt Frankfurt am Main,
Amt für Gesundheit (Peter Waterstraat); Stadt Frankfurt am Main, Der Magistrat – Brand-
direktion (Volker Wilken); Stadt Gladbeck, Feuerwehr (Peter Frank, Manfred Labotzke)
Pilot training in Oslo (NO): The Norwegian center for hearing and mental health, Oslo Uni-
versity Hospital, specialized in the assessment and treatment of mental health disorders
of hearing impaired (Fifteen clinical staff members attended, among others: Britta Barman
Wold, Marianne Eliassen, Beate Øhre, Lene Randa Nilsen, Hege Saltnes, Hanne Urnes); The
Norwegian centre of violence and traumatic stress studies (Marianne B Hansen, Trond
Heir, Marianne Jakobsen)
Pilot training in Odense (DK): Capital Region Psychiatry/Psychiatric Center Ballerup, Deaf
Team (Annebrit Hjort, Per Jensen, Jeannette From Taubert); Center for Deaf, Odense; 1st
interview participant (Susanne Ørum -Sign Language interpreter); Center for Disability,
Technical Support and Social Psychiatry, Social Services (Hanne Langeland); Center for
Emergency Communications, National Police (Steen Herlev Larsen); Center for Psycho-
traumatology, University of Southern Denmark (Anders Elbæk Christoffersen, Ask Elklit,
Sources • 213
Tina Jeppesen, Lotte Skøt); Danish Deaf Association (Lars Knudsen, Jørgen Sandholt – Sign
Language Interpreter); FALCK Healthcare, Psychologist Unit (Helle Berentzen); Police
School, National Police (Lotte Krag); Private clinic (Pia Nielsen); Rescue Center Denmark
(Eigil G.R. Hvid); The Rescue Workers’ Developmental Secretariat (3F) (Mikkel Andersen,
Martin Zimling)
1st International Conference in Prague/CZ – 2013: APPN, 365 o.p.s,Czech Republic (Pavlína
Spilková); ASNEP, European Forum of Sign Language Interpreters (EFSLI). Institute of
the Deaf for Specialized Education, Teiresias – Support Centre for Students with Special
Needs, Czech Republic/USA (Tim Curry); Assistance for visually impaired, Czech Republic
(Jaroslav Rusnák); Association of the Deaf and Hard of Hearing in the Czech Republic
(Farah Curry, Pavel Šturm); Austrian Red Cross, Austria (Ruth Warger); Bavarian association
of blinds and visually impaired, Germany (Svenja Seibold); British Red Cross, UK (Moya
Wood-Heath); Center for psychotraumatology Krefeld, Germany (Robert Bering, Floren-
tine Gerwinn, Simone Ludwig, Christina Schlossmacher); Charles University in Prague,
Czech Republic (Barbora Balková, Hedvika Boukalová, Simona Hoskovcová, Martina
Míčková, Merle van den Akker, Anna Vojtíšková, Štěpán Vymětal); Czech Blind United,
Czech Republic (Rudolf Volejník); Czech Union of the Deaf, Czech Republic (Martin Novák);
Danish Deaf Association, Denmark (Lars Knudsen, Vibe Michelsen, Jørgen Sandholt);
Department of Health, London, UK (Gillian Dacey); Dutch knowledge & advice centre
psychosocial care concerning critical incidents, IMPACT/Arq, The Netherlands (Annelieke
Drogendijk); Expert with visual and hearing disabilities, University in Budapest, Hun-
gary (Krisztina Kovács); Federal Office of Civil Protection and Disaster Assistance, BBK,
Germany (Claudia Schedlich, Gisela Zurek); Federation of Parents and Friends of Hearing
Impaired, Czech Republic (Věra Doušová); Fire and Rescue Service of the Czech Republic
(Jaroslav Gondko, Soňa Pančochová, Zuzana Vrbová); German Deaf Association (Wolfgang
Bachmann); Israel Trauma Coalition, Israel (Talia Levanon, Ruvie Rogel); Ministry of
Interior of Bulgaria (Ilina Nikolova); Ministry of Interior of the Czech Republic (Magda
Koutková, Štěpán Vymětal); Norwegian Centre for Traumatic Stress Studies, Norway
(Marianne Hansen, Trond Heir, Hanne Urnes); Psychologist-expert, assistance for visually
impaired, Germany (Claudia Susanne Heinrich); RISC Slovakia (Lenka Juričeková); Swedish
National Centre for Disaster Psychiatry, Sweden (Philip Arnberg); The Spanish Society for
Psychotraumatology, Traumatic Stress and Dissociation, Spain (Francisco Orengo Garcia);
University of Cologne, Germany (Thomas Kaul); University of Innsbruck, Austria (Heidi
Ulrike Siller, Ruth Warger); University of Ottawa/CA (Tracey O’Sullivan); University of
Sheffield, UK (Graham Turpin); University of Southern Denmark (Ask Elklit, Tina Jeppesen,
Lotte Skøt); University of Zagreb, Croatia (Helena Bakic)
2nd International Conference in Cologne (DE) – 2014: Arbeiter-Samariter-Bund, Germany

(Heinz Rembor); Association of German Professional Psychologists, Germany (Gabriele
Bringer); British Red Cross, UK (Moya Wood-Heath); Center for Psychotraumatology
Krefeld, Germany (Robert Bering, Florentine Gerwinn, Simone Ludwig, Lena Richter
Christina Schlossmacher, Jennifer Söhn); Charles University in Prague, Czech Republic

(Hedvika Boukalová, Simona Hoskovcová); Civil Protection Luxembourg-Psychosocial
Intervention Team (GSP), Luxembourg (Charles Brück); Czech Deaf and Hard-of-hear-
ing Association, Czech Republic (Marie Dolezalova, Barbora Herzanova); Danish Deaf
Association, Denmark (Lars Knudsen, Vibe Michelsen, Jørgen Sandholt); Deputy Executive
Secretary of the European and Mediterranean Major Hazards Agreement of the Council
of Europe, France (Mechthilde Fuhrer); Dutch Knowledge & Advice Centre for Psychoso-
cial Care Concerning Critical Incidents (IMPACT/Arq), Netherlands (Magda Rooze); Escola
Superior de Saúde de Portalegre, District Coordinator from Civil Protection Psychosocial
Intervention Team in Crisis and Emergency Situation, National Civil Protection Coor-
dination Group, for the National Civil Protection Psychosocial Teams development,
Portugal (Miguel André Telo de Arriaga); European Forum of Sign Language Interpreters
(EFSLI). Institute of the Deaf for Specialized Education, Teiresias – Support Centre for Stu-
dents with Special Needs, Czech Republic/USA (Tim Curry); European Union of the Deaf,
Belgium (David Hay); Federal Office of Civil Protection and Disaster Assistance (BBK), Ger-
many (Verena Blank-Gorki, Annika Fritsche, Tobias Hahn, Lisa Krapp, Mark Overhagen, Rike
Richwin, Claudia Schedlich, Ralph Tiesler, Gisela Zurek); German Association of the Blind
and Visually Impaired/European Association of the Blind, Germany (Jessica Schröder);
German Deaf Association, Germany (Wolfgang Bachmann); German National Working
Committee on Fire Brigades, Germany (Jochen Stein); Instituto Europeo di Psychotrau-
matologia e Stress Management, Italy (Bruno Cappagli); International Deaf Emergency,
USA (Emmanuel Jacq); Israel Trauma Coalition/The Community Stress Prevention Center,
Israel (Mooli Lahad, Talia Levanon); Ministry of the Interior of the Czech Republic, Czech
Republic (Barbora Balková, Štěpán Vymětal); National Center for Hearing Impairment and
Mental Health, Norway (Hanne Urnes); Norwegian Centre for Traumatic Stress Studies,
Norway (Marianne Hansen, Trond Heir, Randi Saur); Rush University-Medical Center
(Stevan Hobfoll); Sign Language Interpreters (Inger Caludan and Jorgen Sandholt/DK,
Cindy Cave/BE, Tim Curry/CZ/USA, Britta Meinecke and David Niemann/DE); The Spanish
Society for Psychotraumatology, Traumatic Stress and Dissociation, Spain (Francisco
Orengo Garcia); University of Southern Denmark (Ask Elklit, Tina Jeppesen, Lotte Skøt)
Full account to following organizations, participants and speakers of workshops and

trainings of EUNAD IP:
Local workshop in Innsbruck (AT): Austrian Red Cross Tirol (Bernd Döring); Lebenshilfe
(Martin Reiter); Psychotherapist (Walter Krug); Tiroler Soziale Dienste (Michael Wieser);
University of Innsbruck (Judith Leitner, Barbara Juen, Alexander Kreh, Priya-Lena Riedel)
Local workshop in Czech Republic (CZ): Centre of Social Services Tloskov (PhDr. Matěj Lip-
ský); Charles University (PhDr. David Čáp, PhDr. Hedvika Boukalová, PhDr. Simona Hosk-
ovcová, PhDr. Štěpán Vymětal); Children Centre Paprsek (Mgr. Vanda Prasetová); Children’s
Sources • 215
hearing center Tamtam o.p.s. (Mgr. Věra Doušová); Czech Police, Svět záchranářů (por.
PhDr. Zdena Papežová); DG Fire and Rescue (Plk. PhDr. Zuzana Vrbová, Plk. PhDr. Martina
Wolf Čapková); Domov Na Hrádku (PhDr. Jana Pilná, Milena Strasserová); Emergency Medi-
cal Service of South Bohemia Region (PhDr. Zuzana Fajtlová, DiS.); Fire and Rescue (Nstrm.
Jaroslav Gondko, Kpt. Mgr. Soňa Pančochová); Laguna Psáry (Mgr. Jakub Adámek); Ministry
of Interior (Mgr. Michaela Kvasničková); Nautis (Kateřina Šulcová); Psychiatric Hospital
Bohnice (Bc. Šárka Čadová, DiS.); Retirement home Blaník (Mgr. Oldřich Kumprecht)
Local workshop in Cologne (DE): Alexianer GmbH (Robert Bering, Arno Fuhrmann, Flor-
entine Gerwinn, Maria Jäger, Jennifer Neumann); Caritas Freiburg (Réka Balog, Susanne
Schmid); Färbereizentrum für Integration und Inklusion (Ellen Dieball, Andrea Otto-Er-
ley); Federal Office of Civil Protection and Disaster Assistance (BBK) (Frederike Albers,
Claudia Schedlich); Institut Kompass (Claudia Schmidt); LVR Klinik Bedburg-Hau (Birgit
Skiba); LVR Langenfeld (Johannes Köhler); Medical Centre for people with disabilities
(MZEB) (Bettina Saathoff); Projectgroup: Psychology for people with mental disabilities in
emergency situations (Dieter Irblich); University of Cologne (Lena Grüter); University of
Würzburg (Thomas Spaett)
Local workshop in Oslo (NO): Sunnaas rehabilitation hospital/The Norwegian Association

for visual impaired and blind (Anne-Mette Bredahl – Psykolog and researcher); The Nor-
wegian Association for visual impaired and blind (Gry Berg, Anne Irene Dæhlien, Sverre
Fuglerud, Stian Innerdal, Juridisk Rådgiver, Martin Smestad)
Local workshop in Denmark (DK): Center for Psychotraumatology University of Southern

Denmark (Sarah Dokkedahl, Ask Elklit, Sille Løkkegaard, Sophia Selsbæk, Louise Simonsen,
Adnan Todorovac), Odense University Hospital (Carsten Madsen); participants, five with
physical disabilities (Anne Sophie Byder, Amalie Gersbo-Christiansen, Jeanne Gravfort
(Arm-leg deficit organization), Mette Huus, Birgit Kirk-Knudsen, Michael Købke, Kimmie
Koch, Katarina Korn, Sofie Krogh (muscular dystrophy), Albert Larsen (disabled veteran),
Nanna Lindekilde, Bente Meldgaard, Helle Poulsen, Annelie Preuthun, Camilla Søderquist,
Karen Thaulov, Martin Thomsen (disability assistant); Psykologerne Fyn (Mariann Krogh);
Special Hospital (Ellen Madsen); The Danish Association of the Physically Disabled
(Susanne Olsen)
Expert meeting for Toolkits in Germany (DE): Berufsverband Deutscher Psychologinnen

und Psychologen (BDP), Projektgruppe Notfallpsychologie für Menschen mit geistiger
Behinderung (Dieter Irblich); Carl von Ossietzky Universität Oldenburg, Institut für
Sonder- und Rehabilitationspädagogik (Dr. Marie-Christine Vierbuchen); Deutsches Rotes
Kreuz, Landesverband Nordrhein e. V. (Linn Richter); Federal Office of Civil Protection and
Disaster Assistance (BBK) (Frederike Albers, Volker Harks, Claudia Schedlich, Gisela Zurek);
Julius-Maximilian-Universität Würzburg, Institut für Sonderpädagogik (Thomas Spaett);
Notfallpädagogisches Institut /Medical School Hamburg (Prof. Dr. Harald Karutz); Verband
Sonderpädagogik e. V. (vds), Bundesverband (Marianne Schardt)
Pilot training in Innsbruck (AT): Austrian Red Cross (Christian Schneider, Heinz Wolf); Aus-
trian Red Cross Tirol (Veronica Biebel); Clinic for medical psychology, Innsbruck, Austrian
Red Cross (Thomas Beck); Lebenshilfe (Elisabeth Spielmann); Lebenshilfe Tirol (Kathrin
Gietl); Psychotherapist (Walter Krug); Tiroler Soziale Dienste (Michael Wieser); University
of Innsbruck (Lena Eberle, Judith Leitner, Sandra Mayer, Yasmin Schüssler)
Pilot trainings in Prague (CZ): (1) Charles University (Zuzana Benešová, PhDr. Hedvika
Boukalová, PhDr. Klára Brousilová, PhDr. David Čáp, Pavlína Doležalová, Martina Hanzlík-
ová, Jan Hurych, PhDr. Simona Hoskovcová, Lucie Kafková, Marek Katrňák, Lenka Khánská,
Kristýna Langrová, Barbora Nebáznivá, Monika Plesníková, Eva Pražáková, Kristýna Rissová,
Barbora Soldátová, Iveta Štěrbová, Hana Vostřelová, Karolína Ženíšková); Czech Ministry
of Interior (Mgr. Michaela Kvasničková, PhDr. Štěpán Vymětal); Tamtam o.p.s. (Mgr. Věra
Doušová) (2) Centre of social Services Tloskov (PhD. Matěj Lipský); Charles University
(PhDr. Hedvika Boukalová, PhDr. David Čáp, Karolína Faberová, PhDr. Simona Horáková
Hoskovcová, Marie Schmidtová, Julie Žalmanová); Czech Army (Plk. Mgr. Marek Nový,
Npor. Mgr. Romana Plchová, Npor. Mgr. Patrik Weiss); Czech Ministry of Interior (DiS.,
mjr. Mgr. Tomáš Adámek, kpt. PhDr. Michal Černík, Mgr. et Mgr. Eva Chybíková, nstržm.
Tomáš Frejka, pprap. Tomáš Gotvald, PhDr. Irena Gruberová, kpt. Mgr. Pavel Hurta, DiS Bc.
Ivan Jakůbek, mjr. Mgr. Marcela Kopaňáková, mjr. Mgr. Vladimíra Kvapilová, Mgr. Michaela
Kvasničková, nstržm. Mgr. Antonín Labaj, Ph.D., por. Iveta Losmanová, DiS., kpt. Mgr. Jana
Majzlíková, nstržm. Mgr. Lukáš Malík, por. Bc. Monika Malinová, kpt. Mgr. Kateřina Olex-
ová, kpt. Mgr. Barbora Pálková, nstržm. Jan Peták, DiS mjr. Mgr. Ondřej Sezima, pprap.
Mgr. Miroslav Švandelík, nstržm. Josef Ulrich, por. Bc. Jana Váchová, nprap. Ing. David Vrzal,
PhDr. Štěpán Vymětal, kpt. Mgr. Marek Ženata, nprap. Mgr. Václav Zíka); Czech Police
(kpt. Mgr. Zuzana Baranová, nprap. Bc. Adriána Blažková, Mgr. Jana Francová, Mgr. Veronika
Hejtmánková, kpt. Mgr. Lenka Knitlová, nprap. Bc. Tomáš Komárek, PhDr. Alexandra Mach-
ková, Bc. Milan Mádr, Zdeněk Pleva, nprap. Roman Skopal, Mgr. Petra Svatoňová, prap., kpt.
PhDr. Lenka Vlášková, pplk. Ing. Miloš Zajíc, kpt. Mgr. Vladimíra Žbánková); DG Fire and
Rescue (kpt. Mgr. Martina Wolf Čapková, plk. PhDr. Zuzana Dittrichová); Fire and Rescue
(kpt. Mgr. Soňa Pančochová); Police Presidium (Aneta Langerová); Psychiatry Prague
(MUDr. Jana Schmidtová); Psychosomatic Clinic Prague (Mgr. Zuzana Hrušková); Tamtam
o.p.s. (Mgr. Věra Doušová)
Pilot training in Krefeld (DE): Alexianer GmbH (Robert Bering, Sonja Bühning, Jennifer
Neumann, Jennifer Söhn); Bundesamt für Bevölkerungsschutz und Katastrophenhilfe
(BBK) (Claudia Schedlich); Zentrum für Gehörlosen Kultur Dortmund (Claudia van
Vrijalden Hoven); DeafMentoring (Mauela Bittner); Diakoniewerk Essen (Birgit Dechêne,
Mechthild Schmiedel); Erziehungshilfe e. V. (Marie-Wilhemine Schaper, Alice Wiede-
mann); LVR Rheinland (Horst Bruns); Gesundheitsamt Düsseldorf (Dominique Kok);
Sources • 217
Gesundheitszentrum Gehörlose (Stefanie Breiteneder); Integrationsfachdienst (Tatjana

Mundhenk); LVR Luise-Leven-Schule (Elke Flohr); St. Vinzenz-Hospital Dinslaken (Lena
Schwenke); Theodor-Schäfer Berufsbildungswerk (Oliver Rien); Universität zu Köln (Nele
Büchler, Sonja Denker, Anne Gelhardt); Verein für Hörgeschädigtenhilfe Paderborn e. V.
(Astrid Marke); Vestische Kinderklinik (Karen Jahn)
Pilot trainings in Oslo, Norway (NO): (1) The annual meeting for The Norwegian Association
for visual impaired and blind, 150 participants. (2) Training for clinical psychologists in
specialist courses, 23 participants. (3) Training for clinical psychologists in specialist courses,
25 participants. (4) Training for medical students, 50 participants. (5) Training for medical
students, 50 participants. (6) Training for medical students, 50 participants
Pilot trainings in Odense, Denmark (DK): Center for Psychotraumatology, University of

Southern Denmark (Sarah Dokkedahl Ask Elklit, Beatriz Ponce de Leon, Sophia Selsbæk,
Louise Simonsen, Adnan Todorovac); Rare Diseases and The Danish Association of the
Physically Disabled (five participants with physical disabilities: Jeanett Gravfort, Tina Eliza-
beth Hansen, Michael Købke, Susanne Olsen, Martin Thomasen)
European training, Federal Academy for Crisis Management, Emergency Planning and Civil
Protection (AKNZ), Ahrweiler (DE): Civil Protection Luxembourg, Luxembourg (Charles
Brück); Croatian Red Cross, Health and Social Welfare Department, Croatia (Lorena Brkić);
Directorate General of Health Portugal, Division of healthy lifestyle, Portugal (Miguel
T. de Arriaga); Federal Office of Civil Protection and Disaster Assistance (BBK) Germany
(Frederike Albers, Volker Harks, Claudia Schedlich, Gisela Zurek); Lithuanian University of
Health Sciences, Department Health Psychology, Lithuania (Nida Zemaitiene); Ministery
of Public Health Belgium, Department Disaster Management, Belgium (Astrid S. Fortuin);
Psychological Association Catalunya (COPC), Andorra (Nathalie Garcia Manitz); Public
Health England, Department Emergency Response, United Kingdom (Natasha L. Blood-
worth); University Hospital Bratislava, Slovakia (Miroslava Zimanyiova); University of
Innsbruck, Austria (Alexander Kreh)
3rd International Conference in Cologne (DE) – 2017: Administration des Services de

Secours, Luxembourg (Patrick Friedgen); Alexianer Institut for Psychotherapy, Germany
(Stefanie von der Ruhren); Complutense University of Madrid, Spain (Clara Gesteira
Santos); Civil Protection, Luxembourg (Charles Brück); Cyprus Red Cross Society, Cyprus
(Nikos Papadopoulos); Directorate-General of Health, Portugal (Dr. Miguel de Arriaga);
European Federation of Psychologists’ Associations, Germany (Florian Stoeck); European
Network of (Ex-)Users and Survivors of Psychiatry (ENUSP), Bosnia and Herzegovina
(Sandra Markovic); Fachverband für Menschen mit Hör- und Sprachbehinderung e. V.
(BLWG), Germany (Sören Gericke); Federal Office of Civil Protection and Disaster Assis-
tance (BBK), Germany (Marion Heymel, Ronja Zimmermann); Fire Rescue Service of
Usti nad Labem Region, Czech Republic (Jana Majzlíková); GGD GHOR Nederland, The
Netherlands (Dr. René Stumpel); Groupe de Support Psychologique (GSP), Luxembourg

(Raquel Ferreira); Health Policies at Anti Ghetto – The Project, Bulgaria (Ilina Petrova
Nikolova); Impact, National Knowledge and Advice Centre for Psychosocial Care con-
cerning Critical Incidents/Nivel – Netherlands Institute for Health Services Research, The
Netherlands (Dr. Michel Dückers, Caroline Six); Julius-Maximilians University Würzburg,
Germany (Moritz Kastner, Florian Rubenberger, Thomas Spaett); Lithuanian University
of Health Science, Lithuania (Nida Zemaitiene); Ministry of Norwegian National Unit
for Hearing Impairment and Mental Health (NBHP), Division of Mental Health and
Addiction, Norway (Dr. Beate Øhre); Public Health, Belgium (Astrid Fortuin); Psychiatric
Hospital Kosmonosy, working group for the Psychology of Crisis, Disaster and Trauma
with the CMPS, Czech Republic (Barbora Balkova); Psychological Association Catalunya
(COPC), Andorra (Nathalie Garcia Manitz); Ressource Center for Rare Disorders (TRS), Nor-
way/Denmark (Dr. Anne-Mette Bredahl); Social Work and sign language interpretation,
Germany (Thomas-Paul Gluch); Sociedad Española de Psicotraumatología y Estrés Trau-
mat ico (SEPET-D), Spain ( Dr. Francisco Orengo Garcia); University Hospital Bratislava,
Slovakia (Miroslava Zimányiová); Project Coordinator: Federal Office of Civil Protection
and Disaster Assistance (BBK) Germany (Frederike Albers, Dr. Miriam Haritz, Volker Harks,
Sebastian Hoppe, Claudia Schedlich, Gisela Zurek); Project partners: Centre of Psychotrau-
matology, Alexianer Krefeld GmbH, Germany (Phillip Benz, Prof. Robert Bering, Fernanda
Heinke, Lena Richter, Jennifer Söhn); Charles University, Prague, Czech Republic (Hedvika
Boukalova, Simona Hoskovcova, Stepan Vymetal); Norwegian Centre for Violence and
Traumatic Stress Studies, Norway (Audun Brunes, Marianne Hansen, Trond Heir); Univer-
sity of Innsbruck, Austria (Barbara Juen, Alexander Kreh, Michael Lindenthal); University of
Southern Denmark, Denmark (Sarah Bøgelund Dokkedahl, Prof. Ask Elklit)
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Assisting People with Disabilities

Co-financed by the European Commission

BBK. Working together. Living in safety.

Lectorate and Translation by

© 2017 Federal Office of Civil Protection and Disaster Assistance

German Federal Office of Civil Protection and

Centre for Psychotraumatology

Norwegian Centre for Violence and

University of Southern Denmark

Convention on the rights of persons with disabilities 17

1. Introduction to EUNAD & EUNAD IP 19

2. Target Group Intervention Program 27

2.1 Disaster phases and inclusive disaster risk reduction 30

2.2 Target Group Intervention Program measures 34

3. Analysis of literature and guidelines: summary 45

3.1 Analysis of national and European projects focusing on psychosocial

4. Survey of psychosocial emergency care and uniformed services on their

5.1 Research results 69

5.2 Recommendations for Deaf and Hard-of-Hearing People 75

6.1 Research results 85

6.2 Recommendations for the blind and visually impaired people 92

7. Intellectual disabilities, dementia and autistic spectrum disorder 97

7.1 Literature analysis on people with intellectual disabilities 100

7.2 Research results 113

7.3 Recommendations for people with intellectual disabilities, dementia and

8. Physical impairments 131

8.1 Review of research 133

8.2 Research results 136

8.3 Recommendations for physically impaired people 153

9. Key recommendations for assisting persons with disabilities in case of

9.1 Policy recommendations 160

9.2 Key recommendations for disaster management 162

9.3 Key recommendations for emergency/disaster managers, planners and

9.4 Key recommendations for people with disabilities 168

9.5 Key recommendations for caregivers/family members/

10. Guideline development and implementation: importance of

11. Sources 177

11.1 Research 178

11.2 Guidelines & Handbooks 194

11.3 Tools 202

11.4 Practice Examples 208

11.5 Acknowledgement 210

Figure 1: Adapted from Twigg, (2004) 31

Figure 2: Standard flow chart of target group intervention 35

Figure 3: Target group intervention measures for affected persons 38

The quality of national and European psychosocial crisis management is ensured

The “European Network for Psychosocial Crisis Management – Assisting Disabled

Research, training and workshops represented the milestones of the EUNAD

Both EUNAD projects picked up on the demand of the UN Convention on the

The present recommendations on inclusive psychosocial crisis management

The recommendations are aimed at professionals working in the field of psychoso-

These recommendations on inclusive psychosocial crisis management could

Bonn, December 2017

The States Parties to the present Convention have agreed as follows:

Situations of risk and humanitarian emergencies

Claudia Schedlich, Frederike Albers, Gisela Zurek

Partners in the EUNAD initiative are:

German Federal Office of Civil Protection and

Group de Support Psychologique,

Impact-National knowledge and advice centre for

Israel Trauma Coalition. Response and Preparedness,

Sociedad Española de Psicotraumatología y

Cooperating Partners in the EUNAD initiative are: